July August Issue 2009

VOLUME 14 ISSUE 7/8 JULY/AUGUST 2009 A Publication by the European Society of Cataract & Refractive Surgeons

Advanced Medical Optics is now Abbott Medical Optics Although our name has recently changed from Advanced Medical Optics to Abbott Medical Optics, we are still a name you can trust—one that offers a long history of innovation and market-leading technologies such as: TECNIS® IOL, TECNIS® Multifocal IOL, WHITESTAR Signature™ System, Healon® OVDs, iLASIK® procedure, blink® Tears, and COMPLETE® MPS. The AMO logo, Blink Tears, COMPLETE, iLASIK, and TECNIS are registered trademarks and WHITESTAR Signature is a trademark of Advanced Medical Optics, Inc. Healon is a registered trademark of Advanced Medical Optics Uppsala AB. ©Abbott Medical Optics, Inc., Santa Ana, CA 92705 www.AbbottMedicalOptics.com 2009.03.06-CC888 0(*B$02$EERWWB(XUR7LPHVLQGG30

1 As we approach the XXVII ESCRS Congress in Barcelona, I am delighted to inform EuroTimes readers and ESCRS members that we have renewed our commitment to practice development for ophthalmologists with a comprehensive programme of Practice Development Workshops that will demonstrate to doctors the importance of operational efficiency as well as clinical skills. Details of this programme are included in a brochure which accompanies this issue of EuroTimes and we also have a number of articles which identify some of the key areas which will assist ophthalmologists in developing a vision for their practices. As Dr Jorge Alio, who will be delivering one of the Practice Development Workshops in Barcelona points out, the development of a specific model to suit your practice is more than a business project. It is a shared vision of practice that combines medical assistance and research, where doctors can work together with support from a financial structure. Every person may have a different approach, but they should all have the same vision. Another of our keynote speakers at the congress, Eckhard Weingäertner MD, also emphasises the need for unity of purpose. Dr Weingäertner explains how he spent countless hours recruiting friendly staff, and then rigorously training them in customer service and how to talk to patients and make them comfortable. This of course is only one element of developing a successful practice and we hope that delegates attending the ESCRS congress will welcome the opportunity to hear pearls of wisdom not only from their colleagues, but also from professional marketing and communications experts. One of the exciting things about bringing new ideas into your practice is that it gives you the opportunity to work outside your area of expertise as you develop new skills. That is why I am delighted that for the first time at an ESCRS congress we will have a day long masterclass which will assist ophthalmologists who are considering the first steps to becoming entrepreneurs. Great ophthalmologists don’t always make great businessmen, but Keith Willey Bsc, MBA, who is presenting the inaugural EuroTimes Entrepreneurial Masterclass for Ophthalmologists, says ophthalmologists should not be afraid to put their best ideas forward – even if their basic training is not in business or economics. When I was elected president of ESCRS two years ago, one of my main objectives was to develop an exciting and educational practice development programme and with the assistance of my colleagues on the ESCRS Practice Development Committee, I believe we have gone a long way towards meeting this objective. Of course, we must always look forward and I hope that after the Barcelona meeting we will be able to expand and develop the Practice Development Workshops at our congresses and winter meetings in the years ahead. Paul Rosen is president of ESCRS From the Editor Paul Rosen FRCS, FRCOphth Bring new ideas into your practice with the help of Practice Development Workshops Editorial July/August 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 Medical Editors International Editorial Board BARCELONA 2009 XXVII Congress of the ESCRS 12 – 16 September CCIB Congress Centre Barcelona Spain EuropEan SociEty of cataract & rEfractivE SurgEonS

2 6 Cover Story: Combined surgery for glaucoma treatment 8 OCT imaging provides useful preoperative information 9 Better IOP reduction with combined surgery 10 Joint canaloplasty and cataract surgery provide excellent results Special Focus: New Approaches for Glaucoma 6 Cover Story> 8 Special Focus> 18 Cornea> 31 Cataract> Contents Cataract Update 12 Study shows good visual results with Akreos IOL Refractive Laser 17 Study highlights risks for epithelial ingrowth More Contents 18 Femtosecond laser safe option for PK techniques, but still work in progress Cornea Update 20 Timely diagnosis of post-PK glaucoma crucial to preserve visual function Glaucoma Update

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4 Contents 33 Interview with WOC 2010 president Prof Gerhard Lang Ocular Update 31 Controlling inflammation in uveitic eyes after cataract surgery Retina Update 38 Letter from America 40 In Your Good Books 42 Outlook on Industry 44 Practice Development 46 Legal Matters Features 39 Industry News 41 JCRS Highlights 45 Journal Watch 48 Calendar Regulars 40 Features> 42 Features> 39 Regulars> 45 Features> EUROTIMES ESCRS ™ Published by The European Society of Cataract and Refractive Surgeons The EuroTimes average net circulation for the 12 issues distributed between 01 July 2007 and 30 June 2008 is 27,664 Winner of the PPAI Business-to-Business Specialist Magazine of the Year 2007 Publisher Carol Fitzpatrick Executive Editor Colin Kerr Editors Sean Henahan Paul McGinn Managing Editor Caroline Brick Production Editor Angela Sweetman Senior Designer Paddy Dunne Assistant Designer Janice Robb Circulation Manager Angela Morrissey Contributing Editors Howard Larkin Dermot McGrath Roibeard Ó hÉineacháin Contributors Devon Schuyler Eisele Nick Lane 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 Condolences Dr Eithne Walls and Dr Jane Deasy died tragically in June as passengers on the Air France Flight 447 that crashed into the Atlantic Ocean. Dr Walls commenced her training in ophthalmology at the Royal Victoria Eye and Ear Hospital in Dublin, Ireland, in January 2009. Her friend and colleague, Dr Jane Deasy, was to commence her training in ophthalmology at the Eye and Ear Hospital on July 1, 2009. Junior and senior doctors, nursing colleagues, secretarial and ancillary staff are devastated by the abrupt termination of these promising careers. On behalf of the ESCRS, we offer our profound sympathy to their families. Included with this issue:

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Howard Larkin in San Francisco WHEN Richard B Packard MD, FRCS, FRCOphth was appointed consultant surgeon in Windsor, UK, in 1982, he was doing at least two filtering surgeries a week as a comprehensive ophthalmologist. “Now I probably do four or five a year,” Dr Packard told a session of the 2009 ASCRS Glaucoma Day. Yet he estimates about 10 per cent of the 800 cataract patients he operates on annually have glaucoma. This drop in combined cataract- glaucoma surgeries is an international phenomenon, said Reay H Brown MD, Atlanta, US. Nonetheless, a 2005 study showed that 64 per cent of trabeculectomies in the US were still performed in conjunction with cataract procedures despite sharply reduced volume, he said. “Combined surgery is well-loved by cataract surgeons.” Dr Brown believes the volume drop is related to differing indications for combined procedures compared with filtering surgery alone – and the shifting balance of effort and risk vs reward for combined surgery. In most combined cases, the decision to go to surgery is driven primarily by the presence of a cataract, with the trabeculectomy added to reduce medications for controlling intraocular pressure, Dr Brown said. For filtering surgery alone, on the other hand, continuing optical neuropathy or visual field loss despite medical intervention, or patient intolerance of medication are the primary indications with no cataract present. In the 1990s, when cataract surgery was commonly done through a superior scleral incision, trabeculectomy was a relatively easy add-on, Dr Brown noted. He believes that the switch to clear corneal incisions is a significant, but rarely discussed, factor in combined surgery’s decline. It requires adding a scleral incision, which increases the complexity, risk and operating time. Combined surgery may regain popularity if it can be done temporally in a short time, perhaps 20 minutes or less, he believes. A more commonly discussed reason is improved medical control. Increasingly powerful pharmaceutical agents combined with early detection and better follow- up often result in better IOP control with fewer drugs, Dr Packard noted. If the patient remains stable and tolerates medical treatment well, surgery may never be required. Still, the current low volume of combined procedures raises many issues, not the least of which is whether cataract surgeons can maintain adequate skill performing filtering procedures so infrequently, Dr Packard said. “Should non-glaucoma specialists be doing glaucoma surgery at all?” he asked. The decision to do combined surgery is further complicated by the advent of multiple alternatives to trabeculectomy. Among them are deep sclerotomy, canaloplasty, trabeculotomy, trabecular bypass, and aqueous drainage devices. While many of these procedures have lower complication rates than trabeculectomy, they vary in the degree and duration of their IOP lowering effect, and their technical difficulty. Long- term research to date suggests that trabeculectomy with mitomycin-C still yields the lowest IOP, Dr Packard said. And then there’s phacoemulsification alone. For some patients it may be enough to control ocular hypertension and reduce reliance on glaucoma medications. So how does a cataract surgeon decide which is best for a given patient with ocular hypertension or glaucoma? When is cataract surgery with possible future medical or surgical therapy enough? When does the benefit of reduced complications from an alternative surgery outweigh the risk of additional visual field loss that it might present because it may not reduce IOP as much as a trabeculectomy? Unfortunately, randomised, long-term trials provide limited hard evidence on which to base these decisions, Dr Packard said. However, recent research does support some guidelines, he added. In general, patients with well-tolerated medical glaucoma control should have phacoemulsification alone while those with poor control and/or continuing visual field loss may need a combined approach. The surgery of choice may be surgeon- dependent, but trabeculectomy with mitomycin-C seems to give the lowest pressure, albeit with higher morbidity. The patient’s condition also is a major factor. Whether patients have ocular hypertension alone or also glaucoma signs and symptoms, and the type of glaucoma all influence how well combined and individual therapies work. Phacoemulsification as glaucoma surgery The IOP-lowering effect of phacoemulsification in clear cornea incisions was first reported in 1996 by Debra Tennen MD and Samuel Masket MD, noted Bradford Shingleton MD, Boston, US. That seminal study found IOP significantly reduced in non-glaucoma eyes one year post-surgery. “We found a trend toward lower IOP that, if permanent, raises serious implications about the necessity of combined procedures in patients with both glaucoma and cataract,” the study concluded. These words proved prophetic. Subsequent research by Dr Shingleton and others shows that phaco alone is an effective treatment for ocular hypertension and glaucoma in many patients. “Phacoemulsification is the most commonly performed glaucoma surgery in the world. Whether it is the procedure of choice is another matter,” Dr Shingleton said. Among the research findings are that the mean reduction in all eyes is modest – about 1.0 mmHg to 3.0 mmHg. In normal and open angle glaucoma suspect eyes the reduction persists for at least five years. More important, in symptomatic open angle glaucoma eyes, phaco alone not only reduces IOP, it cuts the mean number of medications required to control IOP by half, though medications needed to maintain IOP trend up toward pre-surgery levels over time, Dr Shingleton added. Moreover, greater IOP reductions are associated with higher pre-surgery IOP. Reductions ranging up to 10 mmHg have been reported in eyes with preoperative IOP of 25 mmHg to 30 mmHg. Greater IOP reductions are also associated with narrow angles. The thickening of the crystalline lens with age may explain why cataract extraction reduces pressure more in open angle and narrow angle patients with higher preoperative pressures, said Thomas Samuelson MD, Minneapolis, US. After age 24, the size of the eye remains stable, but the lens enlarges significantly. Magnetic resonance imaging studies show that the growing lens pushes the iris forward and the anterior chamber shallows. The ciliary body, trabecular meshwork and Schlemm’s canal are compressed, and angles narrow. This could impede aqueous outflow, Dr Samuelson said. Removing the lens and replacing it with a thinner artificial implant relieves the compression, which may restore outflow, he theorised. Because higher pressures are caused by greater outflow resistance, when the compression is relieved in these patients their outflow improves more than for patients with less compression, explaining their greater pressure drops. “I believe that phacomorphic open angle glaucoma exists. It makes sense that if the lens itself is compromising outflow, if you take it out you will increase outflow,” Dr Samuelson said. These conclusions appear to be supported by a study of narrow angle and chronic angle closure glaucoma by Dr Brown. Eyes with preoperative pressures of over 20 mmHg showed a mean reduction of 5.2 mmHg, or 23 per cent, compared with 3.28 mmHg, or 19 per cent, for all eyes, a statistically significant finding. In addition, higher preoperative IOP also was linked with shallower anterior chambers and shorter axial lengths. “If the eye is too short, the lens takes up too much space. We cannot lengthen the eye, but we can create space by removing the lens,” Dr Brown said. His results were statistically significant enough to satisfy FDA guidelines for medications, Dr Brown said. “If cataract surgery came in a bottle, 6 Can cataract surgery control glaucoma? For less-severe cases, phaco alone may be enough; for more-severe cases, multiple combined surgery options are emerging Cover Story New Approaches for Glaucoma Endoscopic view of Ciliary processes during laser ablation Courtesy of Robert Noecker MD

the FDA would approve it for glaucoma treatment,” he quipped. In a study Dr Shingleton reported involving 1,122 patients with pseudoexfoliation and pseudoexfoliation with glaucoma he found that phaco alone lowered IOP by 1.0 mmHg to 2.0 mmHg for seven years in all patients, though the reduction was not significant after the first year for patients with glaucoma symptoms. However, the active glaucoma cases did require fewer medications to control pressure, though pressure trended upward to pre-surgery levels in later years. Dr Shingleton also noted that the need for follow-up treatment after phaco was small. Only 2.7 per cent of the pseudoexfoliation-only patients required additional treatment, defined as a need for medications to control IOP. The rate was slightly higher for the group that also had glaucoma symptoms, where 3.7 per cent required additional treatment, defined as the need for laser or glaucoma surgery. “There is something about phacoemulsification that is truly beneficial in pseudoexfoliation eyes,” Dr Shingleton said. These findings have prompted Dr Shingleton to shift his own practice preferences. “Multiple factors should go into determining the best surgical choice for patients with cataracts and glaucoma. But in my hands, phaco alone is taking a much broader stance in my armamentarium.” Combined surgery alternatives While cataract extraction alone may be the most appropriate procedure for patients with controlled or modestly uncontrolled glaucoma, the disease can be aggressive, Dr Samuelson noted. The benefits of a combined approach may outweigh the risk for patients who are not compliant with medication regimens, strongly want off medications, require chronic steroid medication, have progressive disease that threatens fixation or those with very low target IOPs, he said. Dr Samuelson said options fall into three categories; complete trabeculo-cannicular bypass, such as trabeculectomy, aqueous drainage devices, or suprachoroidal stents, such as the Solx shunt; Schlemm’s enhancement procedures, including 360 degree canaloplasty with prolene suture, Trabectome procedures, or trabecular bypasses such as the iStent; and endoscopic cyclophotocoagulation, which reduces aqueous production rather than facilitating outflow. Trabeculectomy remains the gold standard for combined procedures in large part because its pressure reducing potential is compelling, said Patrick Riedel MD, Minneapolis, US. The procedure is relatively predictable, quickly performed, and can be used in many forms of glaucoma. Success rates are improving thanks to greater attention to bleb morphology, specifically directing subconjunctival aqueous flow to a broader and more posterior location with the goal of creating a low-lying, diffuse slightly avascular conjunctival bleb. While small incision techniques and foldable IOLs now allow combined procedures through a single scleral incision, he believes that separate site surgery may be best because it allows surgeons to perform their usual clear corneal cataract surgery and reduces complication risks for the trabeculectomy. Steven R Sarkisian Jr MD, Oklahoma City, US, described the Ex-Press Mini Glaucoma shunt. He reported a recent published case series of 345 eyes demonstrating a success rate of 95 per cent with three years’ follow-up in getting an IOP as low as is seen with trabeculectomy; however, the surgeon uses a 26-gauge needle under a small scleral flap rather than a large 1-2mm scleral incision, said Dr Sarkisian. No iridectomy is required, and the implant can easily be inserted superiorly in combination with a temporal phaco procedure. Dr Sarkisian compared the advance of the Ex-Press from trabeculectomy to advances in cataract surgery in which we have evolved from a large 10-13mm incision to a 2.2mm incision. The Trabectome makes possible an internal approach trabeculotomy through a temporal corneal incision, said Brian Francis MD, Los Angeles, US. The hand piece is advanced to the nasal angle under gonioscopic viewing and the tip is compressed through the trabecular meshwork into Schlemm’s canal. The TM and inner wall of Schlemm’s canal is ablated, exposing the outer wall of Schlemm’s canal and collector channels unobstructed by any meshwork debris. When combined with phaco, success rates, defined as 20 per cent or greater reduction in IOP or decreased medications and no additional glaucoma surgery, exceed 90 per cent at three years, Dr Francis said. The procedure can be used with many types of glaucoma except neovascular glaucoma, or in patients where the angle structures cannot be properly visualised. Canaloplasty is a viable choice for patients with uncontrolled open angle glaucoma as well as situations where a trabeculectomy might fail or cannot be tolerated due to lifestyle or occupational considerations, said Howard Barnebey MD, Seattle, US. The procedure is non- invasive, does not create a bleb, offers fewer complications and has comparable IOP lowering to trabeculectomy, he said. Drawbacks include technical difficulty and longer operative time however, the adoption proves well worth the effort and similar to the learning curve associated with learning phaco. Canaloplasty is not indicated for angle closure, plateau iris or neovascular glaucoma. The iStent offers the advantage of fewer and less severe complications, said Carlo E Traverso MD of the University of Genova, Italy. The device is essentially a miniature snorkel with one end open protruding into the anterior chamber and the other end inserted into Schlemm’s canal to allow aqueous fluid to bypass blocked trabecular meshwork. The device is implanted through a 1.5mm corneal incision with no sutures and is held in place by three ridges on the long arm of the stent that is inserted into Schlemm’s canal. However, the need for additional treatment to control IOP may be higher than for some alternatives. Some studies suggest that two iStents work better than one. Endoscopic cyclophotocoagulation reduces IOP by slowing the inflow of aqueous by ablating the ciliary processes that produce it, said Robert Noecker MD, Pittsburgh, US. Typically 270 to 360 degrees are ablated. IOP drops for several days after the procedure, with the ultimate post-op pressure reached somewhere between the second and eighth week. Combining the procedure with phaco results in prolonged IOP reduction medications required, whereas pressure tends to trend toward pre-op levels when it is performed alone. As these newer, less risky procedures establish a track record over time, combined surgery could make a comeback for less severe cases, Dr Samuelson said. Each holds the potential to reduce or eliminate dependence on medications without the risks of managing a bleb. However, “the new procedures must prove their mettle to be combined with cataract extraction for early or controlled disease,” he added. eyequack@vossnet.co.uk reaymary@comcast.net bjshingleton@eyeboston.com twsamuelson@mneye.com pjriedel@mneye.com steven-sarkisian@dmei.org bfrancis@doheny.org hbarnebey@specialtyeyecarecentre.com mc8620@mclink.it noeckerrj@upmc.edu 7 Cover Story New Approaches for Glaucoma “Multiple factors should go into determining the best surgical choice for patients with cataracts and glaucoma” Bradford Shingleton MD Richard PackardRobert NoeckerHoward Barnebey EUROTIMES ESCRS PODCAST www.eurotimes.org Visit www.eurotimes.org to read the latest issue and access our complete range of online services The latest ophthalmology news and views online from EuroTimes

Dermot McGrath in Rome THE use of optical coherence tomography (OCT) (Visante, Carl Zeiss Meditec) means that cataract surgery can now be carried out safely in eyes with very low anterior chamber, thereby helping to prevent the onset of angle-closure glaucoma in these high-risk patients, according to Matteo Piovella MD. “Thanks to OCT we now have a method to easily and routinely measure the anterior chamber depth, angle width and corneal thickness. The method is non- contact and completely safe and allows us to define the optimal surgical strategy for our patients, and in particular those patients with low anterior chambers and narrow angles,” he said. Addressing delegates attending the 13th ESCRS Winter Meeting, Dr Piovella, Centro Microchirurgia Ambulatoriale, Monza, Italy, said that recent advances in technology and techniques means that cataract surgeries are becoming increasingly personalised to address the needs of individual patients. “Cataract surgery is improving all the time and now we are faced with new opportunities for our patients. With new preoperative examinations, selection of the dominant eye, greater control of biometry and pupillometry, advanced multifocal IOLs and anterior segment OCT, we really are moving towards more personalised surgery,” said Dr Piovella. The introduction of OCT imaging technology has been especially helpful in providing detailed preoperative information on important anterior chamber features, added Dr Piovella. “The anterior chamber shape can be evaluated bearing in mind all of the key parameters, such as the anterior chamber depth for endothelium safety, the extent of the chamber angle, and the internal dimensions of the chamber to respect the iris and pupil,” he said. He added that the technology is also useful in helping the surgeon to gauge the forward movement of the crystalline lens that occurs due to age-related thickening over time and ensure safety margins are respected for any lens implantation. In patients where a narrow angle has been identified using OCT technology, the surgeon is then in a position to adopt an appropriate surgical strategy, said Dr Piovella. “For example, when we have a low anterior chamber with narrow angles, we routinely use double filling with cohesive and dispersive ophthalmic viscosurgical devices to preserve the surgical space, protect the endothelium and allow safer capsulorhexis management. We also make sure to perform a carefully controlled capsulorhexis since this is more difficult in patients with a shallow anterior chamber,” he said. In terms of patients at risk of glaucoma, Dr Piovella noted that clinical experience has demonstrated that cataract extraction causes deepening of the central anterior chamber and widening of the angle. Furthermore, as the crystalline lens thickness increases over time, there is an increase in angle crowding with predisposition to relative pupillary block. For these reasons, cataract extraction has been advocated as a prophylactic measure in eyes with primary angle closure. Looking at the potential implications of removing the crystalline lens in patients at high risk of angle closure glaucoma, Dr Piovella cited several advantages for these patients, including the reduced need for iridectomy, the reduced need for topical glaucoma therapy – often administered over many years – and hence the reduced social cost of glaucoma. He also emphasised the fact that many of these patients will eventually need cataract surgery anyway, but that the surgery is much more complicated in patients with concomitant glaucoma. In order to assess whether these theoretical benefits translated into clinical outcomes, Dr Piovella recently carried out a study of 45 patients with shallow anterior chamber and narrow angles. The selection criteria included an anterior chamber depth of less than 2.4mm, a narrow angle (defined as less than 15 degrees) and all patients older than 50 years of age. One year postoperatively, the mean anterior chamber depth increased from 2.2mm preoperatively to 3.8mm, or an increase of 73 per cent. There was also a dramatic improvement in the angle width, which showed an average increase of 194 per cent from the preoperative to the postoperative outcomes, said Dr Piovella. He added that the results for intraocular pressure were also considerably improved at the one-year follow-up point. “We are all familiar with the improvement in IOP control after cataract removal and many of these patients now no longer need drugs to control their IOP after surgery. In our series, the preoperative IOP average of 16 mmHg was reduced to 13 mmHg one year after surgery, a decrease of 21 per cent,” he said. On a more cautionary note, Dr Piovella noted that the data for endothelial cell counts illustrated the fact that these patients are particularly challenging for the cataract surgeon. “The average endothelial cell loss for standard cataract cases is around five per cent after six months, but this figure was 21 per cent in our series of eyes with low anterior chamber and narrow angle. This serves to highlight the fact that this surgery is more difficult, more challenging and the age criteria needs to be strictly respected,” he said. Summing up, Dr Piovella said that the Visante OCT is a valuable tool in helping surgeons to identify eyes with shallow anterior chamber and narrow angle in order to improve the surgery outcomes in these complex cases. piovella@piovella.com Courtesy of Matteo Piovella MD 8 Matteo Piovella Cataract removal shows promise as prophylactic measure in angle-closure glaucoma Special Focus New Approaches for Glaucoma “Cataract surgery is improving all the time and now we are faced with new opportunities for our patients” Don’t Miss Legal Matters Page 46

Stefanie Petrou Binder MD in Munich THE combination of phacoemulsification/ cyclophotocoagulation surgery allows patients the benefit of better intraocular pressure (IOP) reduction, reports Markus Kohlhaas MD, St Johannes Hospital, Dortmund, Germany. “Glaucoma therapy seeks to maintain the visual field and optic nerve, and ultimately the quality of life in patients suffering from impaired vision due to chronic increased IOP. Performing cataract surgery along with endoscopic cyclophotocoagulation in glaucoma patients with cataract has an additive pressure reducing effect. It is relatively gentle on the eye, since it is precise, uses low energy, and targets certain tissues only. It has limited applicability, however, as it is only indicated in certain cases,” Dr Kohlhaas told a session of the 23rd Congress of the DGII (German Speaking Society for Intraocular Lens Implantation, Interventional and Refractive Surgery). Dr Kohlhaas performed endoscopic cyclophotocoagulation (ECP) together with cataract surgery in 54 patients. He included patients with chronic open angle glaucoma, pseudophakic patients, patients who have achieved their target IOP through pharmacologic therapy but who have difficulty with compliance, patients whose IOP lies just above their target IOP, and glaucoma patients refractory to therapy, who also required cataract surgery. The average age was 73.8 years with a range from 42 to 87 years. All 54 patients received general anaesthesia for the surgery. This specialised combined surgical technique begins with phacoemulsification and intraocular lens (IOL) implantation. He performed phacoemulsification through a routine corneal incision running parallel to the limbus. For ECP, he implemented a 20 gauge endoscope, with a light source, diode laser (810nm), and an optic with a video system and 110° field range. Dr Kohlhaas used heparin coated IOLs to avoid the potentially strong fibrin exudation into the anterior chamber. After implanting the IOL, he used the endoscope to enter the eye through the anterior chamber or the pars plana, making an incision of 2.5 – 2.8mm. He used the laser to coagulate 320° – 340° of the ciliary body, carefully using the endoscope’s viewer. The working distance was 1.0mm. He used a viscoelastic substance to protect the posterior chamber. The energy input was 0.2 – 0.35 watts. The average IOP pre-operatively was 20.3 mmHg (13 – 35 mmHg). One month, three months and six months postoperatively, it was 12.2 mmHg (2 – 28 mmHg), 12.8 mmHg (4 – 24 mmHg) and 12.7 mmHg (5 – 22 mmHg), respectively. The results indicated that the effectiveness of the combined procedure was useful in enhancing the pressure lowering effects, which was also in accordance with a large US study that implemented the combined procedures, Dr Kohlhaas noted. Improvements in visual acuity Vision improved postoperatively. The average preoperative visual acuity was 0.3 (range: 0.01 – 0.6). Postoperatively at one month, three months and six months, visual acuity was 0.31 (range: 0.01 – 0.6), 0.45 (range: 0.01 – 0.8), and 0.48 (range: 0.01 – 0.8), respectively. The average number of preoperative medications for glaucoma was 2.5 (range: 0 -3). This was reduced to 1.2 (range: 0 – 3), 1.0 (range: 0 – 3), and 1.0 (range: 0 – 3), at one, three and six months postoperatively, respectively. Of the 54 patients in the study, there were 29 right eye and 25 left eye surgeries in 21 men and 33 women. Thirty-eight patients had chronic open angle glaucoma, 15 had pseudoexfoliation glaucoma (PEX), and one patient had chronic recurrent closed angle glaucoma. The group had papillary excavation of 0.9 (0.2 – 1.0), which was quite advanced on the average. Furthermore, the patients had between 0-3 previous pressure reducing surgeries (average 0.3) including cyclophotocoagulation surgery and trabeculectomies. The heparin coated IOLs helped to keep cells from adhering onto the artificial lens. The lenses helped greatly to reduce complications, he noted. Complications included 11 patients with fibrin exudation in the anterior chamber, one with hyphaema due to the destruction of the ciliary body, one patient with lasting mydriasis, two eyes with corneal decompensation, and one patient who required a synechiolysis. Further complications included pop effects, which are known from transscleral cyclophotocoagulation and are a sign that too much energy was used in the procedure, Dr Kohlhaas explained. These led to bleeding in the area of the ciliary body and to irritation and inflammation. Hypotony was not observed in this study. It is reported in the literature, however, although it has not been reported in recent years except in conjunction with neovascular-isation glaucoma, he noted. He advised that risks accompanying intraocular procedures in general applied to this treatment, as well. Dr Kohlhaas sought to avoid under- treatment, when an insufficient surface area is treated, by coagulating a larger surface of the ciliary body. In previous studies, coagulating a surface of 180 – 270° often proved to be too little, he said. A postoperative follow-up treatment with steroids and cycloplegia was necessary, and exceeded the duration of time cataract patients require medication after phaco alone. Furthermore, to avoid fibrin exudation, patients are now pre- treated with steroids, as well as long-term post-operatively, he observed. Dr Kohlhaas explained that the ciliary body is heavily perfused, with a capillary network, and has a blood: aqueous barrier. Since it produces aqueous throughout our lives (2 µl / min), attacking the problem of high IOP here made sense, in that irreversibly destroying these blood vessels reduced aqueous production substantially. markus.kohlhaas@joho-dortmund.de 9 IOP drops 30% after combined phaco/endoscopic cyclophotocoagulation Special Focus Markus Kohlhaas New Approaches for Glaucoma “Performing cataract surgery along with endoscopic cyclophotocoagulation in glaucoma patients with cataract has an additive pressure reducing effect. It is relatively gentle on the eye, since it is precise, uses low energy, and targets certain tissues only. It has limited applicability, however, as it is only indicated in certain cases” Check it out on http://myeurotimes.blogspot.com for a unique online view on the world of ophthalmology EuroTimes now has its own weblog!

Stefanie Petrou Binder MD in Munich COMBINING cataract surgery with canaloplasty enhances the intraocular pressure-lowering effect of the glaucoma intervention, while avoiding the complications often seen with bleb-dependent procedures, reported researchers at the 23rd Congress of the DGII (German Speaking Society for Intraocular Lens Implantation, Interventional and Refractive Surgery). “Canaloplasty can be combined with cataract surgery with excellent results. In order to achieve an additional amount of pressure reduction in patients in advanced stages of glaucomatous disease, we would definitely recommend a combination surgery, even in patients with just the beginnings of cataract but with a more advanced glaucoma. We recommend that these patients combine the surgeries to further decrease IOP,” said Norbert Körber MD, AOC Augenzenrum, Cologne, Germany. Dr Körber operated on 28 patients, with an average preoperative IOP of 25.6 mmHg ± 5.6 mmHg. The patients had glaucoma and coincidental cataract. At three months postoperatively, they achieved 11.89 mmHg ± 3.49 mmHg (n = 28 patients), at six months 13.05 mmHg ± 4.02 mmHg (n = 18 patients), at 24 months 11.3 mmHg ± 3.05 mmHg (n = 7 patients), and at 36 months 11.71 mmHg ± 2.9 mmHg (n= 7 patients). Dr Körber noted that 36 months following the combined procedure, the standard deviation associated with the IOP was very low, giving a maximum IOP of 16 mmHg and a minimum IOP of 8.0 mmHg in the patient group. In his experience, these results were exceptionally good, he observed. The surgical procedure begins with a sclerotomy, and the creation of a 250 micron thick parabolic flap. The surgeon prepares the inner scleral flap up to the canal of Schlemm, but not quite reaching the Descemet’s membrane. Pressure changes during phacoemulsification and the mechanical stress during surgery could put the membrane at risk to perforate if the lid were prepared too close to Descemet’s, he explained. Dr Körber performed MICS through the prepared flap opening or bimanual phacoemulsification. Bimanual phaco offered better safety since the flap remained unchanged, while in MICS the entry wound is under the first flap. Once the IOL was injected, Dr Körber finished preparing the inner flap and excised it. He dilated the canal with a microcatheter (IStent) and pulled a 10 – 0 prolene thread through it. He then placed a watertight suture of the external flap. Dr Körber’s experience with simple viscocanalostomy and canaloplasty, without phacoemulsification, revealed reduced IOP from 25 mmHg to 16 mmHg in roughly 100 viscocanalostomy patients, and from 27 mmHg to 14 mmHg in about 100 canaloplasty patients. Both groups were receiving 2.5 medications preoperatively and only between 0.4-0.2 medications 18 months postoperatively. Success was measured by the percentage of eyes achieving 17 mmHg or lower. By these standards, the surgery proved successful in 70 per cent of viscocanalostomy patients and in 87 per cent of canaloplasty patients, with medication. Without medication, the success rate was 42 per cent in viscocanalostomy patients and 83 per cent in the canaloplasty group, who achieved under 17 mmHg IOP. In terms of complications, Dr Körber noted no serious complications in patients with combined canaloplasty and phaco. He observed none of the expected complications that are associated with bleb-based operations, he said. Only a small percentage of patients developed transient microhyphaemae, which could generally be reduced at the end of surgery once the eye regained its tonicity. The hyphemae were in the range of 0.5 to 1.0mm in size, which generally reabsorbs within a week, he said. “In this group there was not one failure. After three years, only one eye required medication. We saw no additional complications than what we would see with canaloplasty alone. This means cataract surgery causes us and the patients no problems. We would rather combine these procedures than give combined drop medications. With a flat anterior chamber and narrow chamber angle, it is of advantage to perform a cataract combination,” he averred. Dr Körber admitted that the surgery was technically challenging. Although the case numbers are still small, he said that the excellent results in IOP reduction without the same complications as bleb- based procedures made the technique well worth the effort. Dr Körber further highlighted the advantages of working without a bleb. Bleb failure following lens extraction can be associated with uveotic glaucoma, neovascular glaucoma, a required period less than six months between trabeculectomy and lens extraction, preoperative IOP in excess of 10 mmHg, patient age of 50 years or younger, and tenon capsule cystic bleb. Intraoperatively, a large cataract incision, failure to adequately close the wound, excessive iris manipulation, vitreous loss, and inadequate fixation or positioning of IOL, are possible, while postoperatively, iridocapsular adhesion secondary to capsulotomy irregularities, postoperative hyphaema, and failure to adequately control inflammation are risks associated with blebs. info@lasik-koeln.info 10 Canaloplasty plus cataract surgery equals even more IOP reduction Special Focus New Approaches for Glaucoma 6/7 6GNGEVKXG/CUGT7TCDGEWNQRNCUV[ $5&/DVHU*PE+ %HVVHPHUVWUD‰H '1UQEHUJ *HUPDQ\ ª      LQIR#DUFODVHUGH ZZZDUFODVHUGH `/DVHULVFRD[LDOWRVOLW `5HOLDEOHSHUIRUPDQFH `3URYHQWHFKQRORJ\ `$GYDQFHGGHVLJQ `6XSHULRURSWLFV (XUR7LPHVB6/7BLQGG “Canaloplasty can be combined with cataract surgery with excellent results. In order to achieve an additional amount of pressure reduction in patients in advanced stages of glaucomatous disease, we would definitely recommend a combination surgery...”

Colin Kerr GREAT ophthalmologists don’t necessarily make great businessmen, but that should not discourage them from looking at ways of developing their practices and coming up with new business models. Keith Willey Bsc, MBA who is presenting the inaugural EuroTimes Entrepreneurial Masterclass for Ophthalmologists at the XXVII ESCRS Congress in Barcelona, Spain on Saturday, September 12, says ophthalmologists should not be afraid to put their best ideas forward – even if their basic training is not in business or economics. One of the first steps to running an entrepreneurial practice is to have a good business plan, says Prof Willey, associate professor of strategic and international management and entrepreneurship at London Business School, “When you do things for yourself you can get lazy,” said Prof Willey, “but when you have bank managers, accountants or investors working with you it is a good stimulus. “It’s also important that before you bring your idea to these people to play around with an idea and see how good it could be,” he said. “One of the main reasons why people cannot get funded is that they do not deserve the funding. If they have the germ of an idea and nothing else, investors will not be interested in their project. It is even worse if they don’t understand the ideas they are presenting.” So lesson one, says Prof Willey, is do your homework and research your market. When you are happy with your first business plan, then go to your bank manager or investors and try and convince them that your idea is a good one but also that it could work. “If I was a really hard-nosed investor, “said Prof Willey, “I would want something really special that is unique and cannot be copied. You need to differentiate yourself, to market yourself and position yourself so that your product or service stands out from anything else on the market. Another important step is to sell your idea to your investors. “Sometimes,” said Prof Willey, “people who work up ideas forget that their ideas are in fact new to everybody else. If you fail to drive home the killer points about why your idea will succeed, it won’t get off the ground. Too often the summary presented to investors is a sort of contents page of the business plan that omits the real hooks – the special things about the team, the market, customers, and timing.” So what makes an entrepreneur? Is entrepreneurship an inherent talent, developed from a young age and developed either on the factory floor, the office or the university or is it more complex? Prof Willey questions that premise and says he is constantly trying to debunk the image of the young tycoon trading marbles in a playground. “Fitness First, the world’s biggest health chain, was started by a 40-year-old accountant. Another student of mine was a research scientist who joined a biotech company that has now become very successful. “If you don’t like anything that is related to the world of commerce, then entrepreneurship is not for you,” said Prof Willey. “My message to ophthalmologists is that all of the entrepreneurs out there are like you and if the circumstances arise, you can be as good as them.” Ophthalmologists, by nature of their training and their experience in practice, may often be wary of taking risks, but according to Prof Willey, risk taking in business, as in medicine, should be carefully calculated. “You may take a few risks in business and the rewards, if your risks work out, may be bigger than your imagination. But if your risks don’t work out, you should not lose the whole business. That is important when you are developing your business plan because you should be able to tell yourself that you are not going to lose your practice if your new initiative is not a success,” he said. Some ophthalmologists may be reluctant to develop their ideas because they don’t have the money, the business background or the structures of established businesses, but Prof Willey says this should not be a deterrent. “You can have a small business and make a lot of money,” he said. “There are big businesses which make a lot of money because of the scale of their operations, but that leaves plenty of niche opportunities for everybody else.” Ophthalmologists who are also entrepreneurs will also need to find new ways of doing things because they may not necessarily have the resources of their competitors. “Necessity is the mother of invention and you have to find new ways of doing things,” said Prof Willey. “Another way of looking at it is that your job, as an entrepreneur, is not to do all the work and put all the money in. Your job as the entrepreneur is to get somebody else to put the money in and to do the work. Decision making is also very important and the decisions that ophthalmologists make in their clinical practices every day are similar in many ways to the decisions they make in business. “You will never survive in an industry if you do not follow basic rules,” said Prof Willey. “One of the things that cause businesses to stutter and fall is poor management. Investing some time in your management skills will increase your chances of success and I think ophthalmologists will understand that principle.” In their basic clinical training, ophthalmologists will learn about the different stages of development of the eyes and again Prof Willey says that these stages can be identified in business models for entrepreneurs. “An ophthalmologist might ask: Am I facing a problem with my patient? Is it unique to me or is it a common problem?” said Prof Willey. “An entrepreneur may ask the same question and the answer is usually the same. Most of the time it is a common problem with common solutions and I can bring somebody in to assist me.” Prof Willey will share these ideas, and many others, in his masterclass in Barcelona and his take home message to ophthalmologists who are taking the first exciting steps in developing new business models is to be brave and to avoid the fear of failure. “Failure is relative,” said Prof Willey. “If you are a venture capitalist, you love to see someone who has had two or three things that have not worked out, because you know that they are going to take all the lessons they have learned and put them into their new venture.” kwilley@london.edu For more details on the EuroTimes Entrepreneurial Masterclass for Ophthalmologists and the EuroTimes Practice Development Workshops see the brochure supplied with this issue of EuroTimes and visit our websites at www.eurotimes.org and www. escrs.org. Also in this issue, see Practice Development Feature page 44. 11 London Business School professor to give entrepreneurial masterclass in Barcelona Practice DevelopmentKeith Willey New Approaches for Glaucoma 2010 EuropEan SociEty of cataract & rEfractivE SurgEonS 14th ESCRS Winter Meeting www.escrs.org February 12-14, 2010 The Corinthia Hotel, Budapest In association with the Hungarian Society of Cataract and Refractive Surgeons (SHIOL)

Stephanie Petrou Binder MD in Munich IMPLANTATION of the Akreos MI60 intraocular lens (IOL) is safe and effective through a 1.8mm incision, according to a multicentre European study presented at the 23rd Congress of the DGII (German Speaking Society for Intraocular Lens Implantation, Interventional and Refractive Surgery) in Munich. “The MI60 gave us very good centration and very little tilting, which is particularly important with ultrathin microincisional IOLs, as has proven to be an issue in the past. The visual results are also quite good,” said Thomas Kohnen MD, Goethe University Eye Clinic, Frankfurt, Germany, who presented the one-year outcomes of this multicentre study. The 24-month, prospective study included 125 patients who received monocular MI60 implants in centres located in five European clinics in Spain, Sweden, Italy, France, and Germany. The Akreos MI60 is a one-piece hydrophilic acrylic ultrathin posterior chamber IOL. It is aspherical in shape with a spherical aberration of 0.0 µm. The device is implanted through a 1.8mm incision, has a four-point fixation, a 360° posterior lens edge, and 10° of haptic angulation. The study outcomes revealed an average IOL strength of 21.2 ± 2.5 D (ranging from 15.5 to 30 D). Mean wound enlargement during the operation was 0.10 ± 0.2mm, which is typical for this kind of surgery and has been verified in a number of other studies, Prof Kohnen observed. The incision size for the phaco portion of the operation was 1.5 ± 0.3mm, because it was performed bimanually. Incision size was 1.7 ± 0.2mm in eyes that had previous implant surgery and reached an average of 1.8 ± 0.15mm after IOL implantation. The uncorrected visual acuity (UCVA) was 0.26 after the first week following surgery. The mean UCVA at one month was 0.23, and remained unchanged at three months. The mean spherical aberration was 0.25 at one week, 0.19 at one month and 0.24 at three months. The average best-corrected visual acuity (BCVA) preoperatively was 0.46. Postoperatively, the values went from 0.11, then 0.4 and 0.2 during the next three follow-up visits. BCVA was 20/20 by the fourth follow-up visit (between day 30 to 60), he noted. Researchers examined tilting and centration in these ultrathin IOLs using Scheimpflug camera imaging at one week to six months post-surgically. The investigators used the NidekEAS-1000, taking images at 180° and 90°. Prof Kohnen noted that the curvature of the anterior IOL surface was suitably shaped to align along the posterior corneal curvature. The calculations were done using the camera’s own software, he said. IOL tilting examinations revealed tilting of between 1.51 to 1.79 degrees in selected patients. Decentration was noted within a range of 0.22 to 0.31 degrees. Comparing the tilting and decentration results with the Akreos from this investigation to his past experience with standard lenses, such as with AcrySof and Tecnis IOLs, showed a smaller degree of tilting with Akreos microincisional ultrathin lenses. Standard IOLs had a tilting of 2.3 to 3.0 degrees and a decentration of 0.23 to 0.29 degrees. The Akreos outcomes were quite comparable overall, he observed. Wavefront analysis was performed in two of the collaborating study centres (Germany and Sweden), using the Zywave aberrometer to study higher order aberrations at one month and three months postoperatively for eyes with 3mm, 4mm, and 5mm pupillary diameter. The third-, fourth-, and fifth- order aberrations increased notably with increasing pupil size. Prof Kohnen used bimanual phacoemulsification to treat the cataracts. He employed topical anaesthesia with a mid-sized clear cornea incision (1.5 ± 1.29mm) in 72 per cent of patients. He enlarged the incisions to an average mean incision size of 1.7 ± 0.2mm. He employed two viscoelastic substances, Amvisc Plus (Bausch & Lomb) which he used in 59 per cent of cases, and Coatel (Bausch & Lomb) in 37 per cent. Prof Kohnen performed 4cm to 6cm capsulorhexes on the optic in 96 per cent of eyes. He also performed posterior capsule polishing in all eyes. The surgical technique was an injection-wound-assisted technique. For device implantation, he used the Viscoject Medical System with a 1.8mm cartridge. The incision was hydrated and no suture was made in 94.4 per cent of the operated eyes. kohnen@em.uni-frankfurt.de 12 Thomas Kohnen Akreos MI60 posterior chamber IOL stable at one year Cataract Update KPVGTPCVKQPCN<+'/'412*6*#./+%5;56'/5#)%*2QTV 5YKV\GTNCPF RJQPG KPPQXCVKQP"\KGOGTITQWREQO 2TQOQVKQPCN%QFG## 7PKVGF5VCVGU<+'/'475#+0%9QQF4KXGT+.RJQPGVQNNHTGGGOCKNWUC"\KGOGTITQWREQO 6JGōVJTGGKPQPGŋ/KETQMGTCVQOG .#5+-CPF5$- 5WTHCEGCDNCVKQPGRK.#5+- .COGNNCT-GTCVQRNCUV[5#.-&#.- YYY\KGOGTITQWREQO &GRGPFCDNG6GEJPQNQI[ 5WRGTKQT4GUWNVU 2GCEGQH/KPF +,*+5(6B$0$'(86BB(7LPHVB$$B[LQSGI

Board Elections 2009 2009 European Society of Cataract and Refractive Surgeons ESCRS Board elections to be held this summer According to the bye-laws of the ESCRS, Board elections are held every two years. ESCRS Board members serve for a term of four years and can be re-elected for one additional four-year term. Board members must have been a full member of the ESCRS for the last three consecutive years and each candidate standing for election must be nominated by five other full members of the society. Ballot papers will be sent to all ESCRS members in July and the deadline for voting is 30 August 2009. There are five positions open on the Board in this election and the names of the new Board members will be announced at the Annual General Meeting of the society in Barcelona in September. The 19 candidates standing for election are profiled below. Since my first meeting in 1987, the ESCRS has played a central role in my professional development. I hope to contribute a unique perspective, representing the interests and concerns of the general membership of the ESCRS. I graduated from Ankara University Medical School and completed my residency training in ophthalmology at S.B. Ankara Hospital Ophthalmology Department. I completed the Vitreoretinal Fellowship at Cambridge University Ophthalmology Department. I am chairman of the Department of Ophthalmology at MESA Hospital as well as maintaining my own private practice. As an anterior segment specialist, my clinical focus is in cataract and intraocular lens implant surgery, with special interest in complicated cataract surgeries, such as after trauma or prior ocular surgery. I have been active in teaching throughout my career. I have been author and co-author of papers and abstracts in peer- reviewed journals, and in papers published as book chapters. I am a member of many national and international professional societies and have served as co-opted Board member of ESCRS since 2008. I am editor of the Turkish online edition of EuroTimes. I have been impressed by the leadership and vision of the ESCRS. As a team, we can affect the progress of our field with medical education, research, and improved physician/patient relations. I am an associate professor, senior ophthalmologist and cataract/cornea surgeon at Umeå University Hospital in northern Sweden. I have been involved in both basic and clinical research on the lens and cornea for a number of years, and have published more than 40 papers on these subjects, of which 18 were published in the Journal of Cataract and Refractive Surgery. I am also the vice-president of the Swedish Ophthalmological Society and a member of the Board of the Swedish National Cataract Register. I have been a member of the ESCRS since 1999, participating in the majority of the annual meetings since, and have followed the impressive development the society has undergone during this time. I now hope to be able to further contribute to the work and development of the society, offering my clinical and basic scientific experience and knowledge to the ESCRS Board. Dr Zsolt Biró, MD, PhD (1958) is a professor and head of the Department of Ophthalmology at the Medical University of Pecs, Hungary. His special interests are cataract and refractive surgery, laser treatment of retinal diseases and retinal detachment surgery. He has published three books, seven book chapters, has over 70 papers published in peer-reviewed journals, and he has given over 210 lectures. He is an invited speaker and performs live surgery in different countries in Europe and in India as well. Dr Biro is the organiser of Hungarian national and international congresses. He is the elected president of the SHIOL (Hungarian Society of Cataract and Refractive Surgeons), co-opted Board member of the European Society of Cataract and Refractive Surgeons (ESCRS), member of the International Intraocular Implant Club (IIIC), and Honorary Member of the Romanian Ophthalmological Society. He is a member of the Editorial Board of “International Ophthalmology”, and a reviewer for several ophthalmology journals (JCRS, EYE, Acta Ophthalmologica, Br J Ophthalmol). 1983-90: Medical School: RWTH University of Aachen, Germany. International education: 1987 Surgery, Ophthalmology, Pharmacology Universitäty Clinic of Turku, Finland, 1988 Internal Medicine, Tropical Medicine, Paediatrics: Albert Schweitzer Hospital, Lambarene, Gabun (West Africa), 1989/90 General Surgery, Vascular Surgery: Kettering General and District Hospital, University of Leicester, England, 1990- 92: Residency in Ophthalmology, Marienhospital Aachen, Germany, 1992-94: Fellowship in Ocular Pathology and IOL Research, Center for IOL Research, MUSC, Charleston, SC,USA (D.J.Apple), 1994-95: Retina Fellowship, Dept. of Ophthalmology, University of Heidelberg, 1996 Board Certification for Ophthalmology, Germany,1997 Faculty Appointment, Dept. of Ophthalmology, Univ. of Heidelberg, 1998/99 Ph.D. Thesis and Professorship for Ophthalmology, Univ. of Heidelberg, 2002 Board Member/Secretary: German Society for IOL Implantation and Refractive Surgery, 2003 Chief Faculty/Vice-Chairman, Dept. of Ophthalmology, University of Heidelberg, 2005 Honorary Member: Hungarian Society for IOL implantation (SHIOL), 2005 ESCRS Board Member 2006 ISO 9001:2000 Certification: International Vision Correction Research Centre, 2009 Acting Chairman, Dept. of Ophthalmology, University of Heidelberg. Core Research Expertise: Cataract surgery, IOLs, OVDs, accommodative, multifocal, toric, aspheric IOLs, femtosecond laser, excimer laser, corneal topography, wavefront analysis, scheimpflug technology. ESCRS Committees: Research committee, Education committee. ESCRS contributions: Improvement of education programme, international exchange and multicentre research studies, better contact and communication with local societies. Bekir Sıtkı Aslan Turkey Gerd U Auffarth Germany Anders Behndig Sweden Zsolt Biró Hungary

2009 Beatrice Cochener France Academic career: Laser research fellow (Beckmann Laser Institute, Irvine, Cal); Professor and head, University Eye Clinic (Brest); SAFIR (French Implant and Refractive Surgery Society) Board member; President, SFO (Société Française d’Ophtalmologie). Personal research and development: Laser applications; Imaging of the eye; Clinical evaluation: phakic and aphakic implants, refractive lasers; Anterior segment surgery teaching. ESCRS Involvement: I have been an active ESCRS member for 15 years, participating in all meetings. As a co-opted Board member since 2007 I have personal experience of the society’s work and dedication. Based on this two years’ service I will warrant: n Independence of mind, to ensure all our members the best possible scientific and medical information; n Continuous and precise attention to our members’ expression, more specifically to new initiatives and possibilities expressed in the winter and September meetings. The ESCRS spirit is made of this permanent renewal of knowledge, through member participation. My commitment to our society can be summarised in one word: SERVICE. Dan Epstein has been active within the ESCRS for the past 10 years. He has been a member of the programme and other committees, an initiator and faculty member of the Refractive Surgery Didactic Course, speaker at the Young Ophthalmologists Programme, faculty at various ESCRS courses, and senior wetlab instructor. He is consultant ophthalmologist for refractive surgery at the Department of Ophthalmology, University Hospital, Zurich, having previously held an appointment at Uppsala University Hospital in Sweden. Earlier he had received a PhD from the Karolinska Institute after completing his residency at the Karolinska University Hospital in Stockholm. In addition to the current university affiliation and a private practice, he is also active in research and the publication of papers, and is an editor of the Journal of Refractive Surgery. If elected to the Board, he hopes to be able to expand his contribution to the society’s evolution in a very competitive field, building on his teaching and planning experience to further enhance the didactic role of the ESCRS in providing superior educational opportunities in Europe and beyond. I have been practising at the S.Fyodorov Eye Microsurgery Clinic (Moscow) for more than 20 years. I was lucky to serve the ESCRS for several years by working as a co- opted Board member, as a member of the Publications Committee and editing the Russian language version of EuroTimes. If I am elected to the Board, I will continue doing my best to strengthen the relationships between the European ophthalmic community and eye care professionals from Russia and surrounding countries, to stimulate the exchange of the new ideas, develop joint educational and research projects and spread the spirit of integrity. We all live in different socio-economical environments, we have a lot of differences but we also have very much in common. The ESCRS is a unique society that can help us not only to be updated in our specialty and to know more, but also to create personal relationships, to meet old friends and to make new ones. And I am absolutely sure that all this will not only make our lives brighter but more importantly - will benefit our patients. QUALIFICATIONS: Medical degree: 1991, Verona (Italy); Residency: 1995, Verona (Italy); Internal doctor, University of Verona (1995 – 1998); Fellow doctor, Hospital and University of Verona (1998 – 2008); Director of anterior segment surgery, Hospital of Verona (2002 – 2008); Director of Ophthalmology Hospital of Bassano del Grappa Italy (2008 – present). DIDACTIC ACTIVITY: Professor of refractive surgery, University of Verona (2001 – present). SURGICAL ACTIVITY: Cataract surgery, refractive surgery, corneal surgery, glaucoma, posterior segment surgery. SCIENTIFIC ACTIVITY: AICCER (Italian Association of Cataract and Refractive Surgery): Board member 2006-2012; Editor of the monthly magazine; responsibility for website; Programme Committee member; Live surgery coordinator; ESCRS: member 1993 – present, active participant at every congress, Young Ophthalmologist Forum participant; Member of ASCRS, AAO, SOI; Author of over 60 publications; Live surgeon 1999 – present. AIM AS ESCRS BOARD MEMBER: Maintain the high quality of ESCRS congresses and education, favouring the continuous growth of the society especially in relation with other European societies; Help young surgeons in their relations with the society, with relevant initiatives both in organisation and in education, i.e. favouring travel and web education; Development of the medical aspect of the website; Improve relationships with Italy and other low membership countries. Oliver Findl is associate professor of ophthalmology and director of the Eye Department at Hanusch Hospital in Vienna, Austria, and is a consultant ophthalmic surgeon at Moorfields Eye Hospital in London, UK. He has been a Board member of the ESCRS for the past four years and will complete his first term of office in September of this year. He is a member of the Education Committee and co-organiser of the Young Ophthalmologists Programme at the annual congress. Dr Findl was a research fellow at the Children’s Hospital, Harvard University, Boston and completed his training at the Medical University in Vienna. His research interests are in the field of optical biometry, PCO and assessment of visual quality after surgery. He has published over 160 peer-reviewed articles in international journals. He is section editor for Reviews & Updates of the Journal of Cataract and Refractive Surgery and an editorial Board member of EuroTimes. His involvement in the ESCRS Board would be to intensify the teaching strategy of the society, both for young trainees as well as for certified colleagues who are seeking further training. Completed Medical School at the University of Belgrade (1983), Residence in Ophthalmology (1991), doctoral thesis (Ocular Trauma in Cataract Surgery) - Military Medical academy Belgrade (1998). From 1991 - 2005 (senior registrar, consultant in ophthalmology) Eye Department Military Medical Academy, Belgrade. Consultant in Milos Clinic Eye Hospital, Belgrade (2005 - present). Elected professor of ophthalmology at Medical Academy - US Medical School, Belgrade, and visiting professor at Medical School University of Nis, Serbia. SOE grant in 1995: four months in San Raffaello Hospital, Milan and St. Erik’s Hospital, Stockholm specialising phaco techniques, refractive surgery and paediatric cataract. International Ophthalmologist Education Award from AAO in 2007. Pioneer and promoter of phacoemulsification in Serbia since 1991, and foldable IOL implantation since 1998. Founder of School of Phacoemulsification in 2000 (academic, wet-lab and hands-on training), with training conducted in over 20 medical centres in Serbia and Montenegro. In 2007 implemented programme and course for phaco- instructors, providing quality control in phaco education in Serbia, Montenegro, Bosnia and Herzegovina. Founder and president of Serbian Society of Cataract and Refractive Surgeons (2007/2008: 130 members, 98 ESCRS members). Contribution to the ESCRS would come from the outcome of ongoing activities and implementing VISION 2020 goals in blindness eradication in Serbia and Balkan region. Branislav Djurovic Serbia Dan Epstein Switzerland Oliver Findl Austria Boris Malyugin Russia Simonetta Morselli Italy Board Elections 2009

Qualifications, Medical University of Lodz, Poland: Physician Diploma (MD) - 1979, First degree specialisation in ophthalmology – 1982, Second degree specialisation in ophthalmology – 1986, PhD – 1988, Assistant Professor Thesis – 2000, Professor Thesis – 2007. Training abroad: Department of Ophthalmology, University of Freiburg, Germany, 1985; Department of Ophthalmology, University of Utrecht, Netherlands, 1991; Tennants Institute of Ophthalmology, University of Glasgow, Scotland, 1992; National Institute of Ophthalmology “Quinze- Vingt” , Paris, France, 1993 – 1994. Membership: ESCRS, Polish Ophthalmological Society, Polish SCRS. Present positions: Head of the Department of Ophthalmology, Medical University of Lodz; chairman of the Section of Cataract and Refractive Surgery of Polish Ophthalmological Society; vice-chairman of Polish Ophthalmological Society. Professional interests: Microsurgery – complex surgery of the anterior and posterior segment of the eye, cataract and glaucoma surgery, pathology of the eye. Publications: Full text articles – 95, in Polish and in English (Brit. J. Ophthalmol,. German J. Ophthalmol., J. Cataract Refract. Surg., Ophthalmic Surg. Lasers Imaging, Eur. J. Ophthalmol.); congress and symposium presentations – 158. If I am elected to be a Board member of ESCRS I intend to enhance co- operation between the ESCRS and national societies of east and middle European countries in the fields of education, symposium organisation and young ophthalmologist training. My fields of expertise are cataract and refractive surgery and I have my practice in Monza, five miles from Milan, Italy. Since 1995 I have been senior instructor on more than 100 courses within AAO, ASCRS and ESCRS. Since 2003 I have been a member of the ESCRS Programme Committee and I was responsible for organising the live surgery programme at the ESCRS Winter Meetings in Rome (2005 and 2009) and in Monte Carlo (2006). I have spent the last 10 years as secretary of the Italian Society of Ophthalmology (SOI) and my hope is to have the opportunity to use my experience to support the development that the ESCRS has planned for the next three years. We all need a European Society that listens to the needs of the ophthalmic community and we should co-operate to decrease the main differences that are present today in ophthalmology across Europe. Professionalism and competence to spread the same scientific formations and guidelines throughout Europe will protect the quality of our surgery and patient care. Sunil Shah is an acknowledged leader, teacher and researcher based at the Birmingham and Midland Eye Centre. He is also an honorary professor at the University of Ulster and a visiting professor at Aston University. He specialises in complex corneal and refractive surgery. He is a past-president of the British Society for Refractive Surgeons, is on the Council for the British Contact Lens Association, on the Refractive Working Party for the Royal College of Ophthalmologists and is a specialist advisor to the National Institute for Clinical Excellence. He is a corneal section editor for the British Journal of Ophthalmology and clinical and experimental ophthalmology and is on the Editorial Boards for European Ophthalmic Review, Contact Lens and Anterior Eye and Ophthalmology Times. Sunil has recently developed a web-based Masters programme in cataract and refractive surgery with the University of Ulster to address some of the problems in teaching this worldwide. As an ESCRS Board member, Sunil would like to help advance all aspects of the ESCRS’s already outstanding work in education and research. The ESCRS is the world’s premier organisation for cataract and refractive surgery and Sunil would strive, with the Board, to expand its audience and impact. 2009 I have been associated with the ESCRS for many years, serving on both the Programme and Scientific Research Committees, and take a very active role both in planning and contributing to our meetings, which I think are the world’s best. I would now like to stand for election to the Board for a second term. I am deeply committed to developing the continuing excellence of our meetings and like to see change through evolution rather than revolution. For the future I would like to see stronger links with Eastern Europe and the society starting to fund serious programme grants for research. I work at St Thomas Hospital, London and am the immediate past president of UKISCRS. My research interests are in IOL design and particularly PCO. I have published 160 papers and teach and lecture internationally. My book, An Atlas of Clinical Ophthalmology is now in its 3rd edition and is published in 10 languages. It won the BMA prize for the best medical textbook of the year in 2005. I am working as a laser refractive surgeon in a private practice. I have certification in laser refractive surgery from the Royal College of Ophthalmologists. I have been performing refractive surgery for the last 10 years and have performed several thousand procedures including LASIK, LASEK and CK. I am actively involved in teaching laser refractive surgery in the UK through didactic courses and wetlab workshops. I am a council member of the British Society for Refractive Surgery. I am also a member of the Ethics Committee of the Royal College of Ophthalmologists. I am interested in becoming a Board member of the ESCRS to help promote education and research in the field of cataract and refractive surgery. I feel I have the enthusiasm and experience needed to assist the Board of the ESCRS to further its commitment to members and grow as a society. If elected I seek to make a significant contribution to the ESCRS by helping to provide training to beginners through courses and wetlab workshops. I will also endeavour to assist the society in administrative matters and planning of future meetings. Vittorio Picardo was assistant professor at University of Rome La Sapienza, Institute of Ophthalmology, from 1978 to 1997. Since 1998 he has been head of the Ophthalmological Department at Casa di Cura “Nuova Itor” - Rome (a clinic operating within the National Health Service). The department has been renovated, increasing considerably the surgical and instrumental activities and the number of surgeries. His field of interest is anterior segment surgery and during his career he has performed more than 15,000 surgeries. He is author of four text books and more than 150 scientific articles (several are in Dr Buratto’s text books on cataract surgery). He is a member of the editorial committee of some Italian ophthalmic magazines. He participates in congresses in Italy and abroad as speaker, coordinator, organiser, round table chairman and surgeon in live surgeries. He has presented more than 150 oral communications in national/international meetings. From 2000 to 2006 he was the scientific secretary of the Italian Association of Cataract and Refractive Surgery (AICCER). He has been a member of the ESCRS video competition jury since 2002. His contribution to the society will encourage activities for younger ophthalmologists, including opportunities to frequent special departments in different countries to increase their knowledge. Wojciech Omulecki Poland Vittorio Picardo Italy Matteo Piovella Italy Malcolm Samuel UK Sunil Shah UK David Spalton UK European Society of Cataract and Refractive Surgeons

Having served one term of four years as Board member, four years as secretary, two years as president and two years as past-president, the logical question is why apply for a second term as Board member? The ESCRS is a dynamic society which has achieved recognition in Europe and worldwide in the field of cataract and refractive surgery. This is the result of close collaboration between European ophthalmologists whose interest is not restricted to surgery but includes teaching, research, organisation and innovation. The role of the ESCRS is ever more challenging regarding its task to offer members the best practical, useful and scientific information. Having finished my term as president of the European Board of Ophthalmology, I realised the need for teaching programmes, basic or advanced, in and outside Europe, within the fields of interest of the ESCRS. It is evident that the ESCRS will have an important role to play and should join the European Network of Education in collaboration with other European sub-specialty societies. Unlike politicians, I am not satisfied with promising without achievements as proved during the first term as elected Board member. I decided to apply for a second term because I would like to continue the work started. Dr Jérôme Vryghem is head of the Ophthalmology Department of the Saint-Jean Clinic in Brussels (Belgium) and medical director of Brussels Eye Doctors. His passion is to apply the latest surgical techniques and he is thus involved in micro-incision cataract surgery, thin flap femtoLASIK surgery, anterior and posterior lamellar corneal surgery, UV-crosslinking and techniques for visual rehabilitation of keratoconus patients. He has been a Board Member of the Belgian Society of Cataract and Refractive Surgery (BSCRS) since 1994. He has organised several scientific meetings and live surgeries, not least, the live surgery of the ESCRS Congress in Brussels in 2000. He has participated in several other international live surgeries. He has directed an ESCRS instructional course on the ‘Prevention and management of complications in LASIK’ since 2001 and has been a faculty member in several other instructional courses. He is a member of the Editorial Board of ‘Cataract & Refractive Surgery Today Europe’ and has written several peer- and non-peer reviewed articles. His ambition as a Board member of ESCRS is to be involved in the Programme Committee of ESCRS congresses and to organise more didactic sessions on hot topics. Manfred Tetz‘s professional education: 1979 – 1986: Medical studies in Germany at universities of Marburg and Aachen to become an MD. 1986 – 1988: Post-doctoral fellowship in Salt Lake City and Charleston, USA with Dr. D. Apple, Center for IOL Research, supported by a Stipend of Alexander from Humboldt-foundation. 1988 – 1992: Residency training, Department of Ophthalmology, University Heidelberg. 1992: Board certification in Ophthalmology. 1993 – 1998: Staff member, Department of Ophthalmology, University Heidelberg. 1998 – 2003: Full Professorship at the Department of Ophthalmology, Charite, Humboldt University, Berlin. 2003: Founder and owner of private eye hospital, Spreebogen Berlin. 2006: Founder of BERI (Berlin Eye Research Institute). Prof. Tetz has been strongly involved in ophthalmic research and teaching with more than 250 scientific publications, over 700 scientific presentations given and numerous awards for presentations, lectures and videos over the last 20 years. He is currently Board member and treasurer of DGII, the German Society of Cataract, Refractive and Interventional Ophthalmology, starting this position in 2002, and Board member of ESCRS, elected in 2005. He would like to continue his services for European cataract and refractive surgery to further promote the high quality research performed in the area under the auspices of ESCRS. Manfred Tetz Germany Jérôme C Vryghem Belgium Board Elections 2009 Marie-Jose Tassignon Belgium ESCRS Membership See the benefits! Reduced Congress FeesEuroTimes EUREQUO Membership Pack Journal of Cataract & Refractive SurgeryMembers’ Area Voting Rights ESCRS on DEMAND - reduced rates European Society of Cataract & Refractive Surgeons, Temple House, Temple Road, Blackrock, Co. Dublin, Ireland Tel: +353 1 209 1100 Fax: +353 1 209 1112 Email:escrs@escrs.org www.escrs.org 16

Devon Schuyler in Atlanta ENHANCEMENT LASIK using flap-lift techniques is more likely than initial LASIK to cause epithelial ingrowth, a study reveals, especially if the enhancement occurred three or more years after the original procedure. “A critical change in the healing of LASIK flaps occurs approximately three years after flap creation that dramatically increases the risk of clinically significant epithelial ingrowth,” said study investigator Andrew I Caster MD, speaking at the annual AAO meeting. Dr Caster is medical director of the Caster Eye Center Medical Group in Beverly Hills, California. Dr Caster’s study was a retrospective review of all the primary and enhancement LASIK procedures he had performed between January 2004 and June 2007. The original flaps were made using one of several mechanical keratomes or the IntraLase. Enhancements were performed up to 10 years after the original procedure, and all involved lifting the original flap rather than cutting a new one. He then identified cases of clinically significant epithelial ingrowth, defined as ingrowth that negatively affected uncorrected or best-corrected visual acuity, and that required treatment. Dr Caster found that epithelial ingrowth was significantly more common after enhancement than after primary LASIK. There were no cases of clinically significant epithelial ingrowth among the 3,866 primary LASIK procedures, compared with 15 cases among the 646 enhancement LASIK procedures – a rate of 2.3 per cent. When Dr Caster further analysed the enhancement cases, he found that the rate of epithelial ingrowth was significantly higher when the enhancement was performed three to 10 years after the original procedure (7.7 per cent) than when it was performed less than three years later (1.0 per cent). Interestingly, the rate of epithelial ingrowth did not increase steadily. The rate was one per cent at zero to one year, two per cent from one to two years, zero per cent from two to three years, 10 per cent from three to four years, and seven per cent after four years. “If you look at each individual year, there seems to be a big dividing line at three years. At the three- to four-year mark, the rate suddenly jumps up,” he said. He added that the seven per cent rate at more than four years remained “pretty much a constant” between year four and year 10. The rate of ingrowth was the same in men as in women (2.1 per cent vs. 2.5 per cent) and did not differ based on the patient’s age. There was a trend toward lower epithelial ingrowth rates among patients who had a routine bandage contact lens placed for the first night post-op versus those who did not (2.3 per cent vs. 4.0 per cent), but this did not reach statistical significance. When clinically significantly epithelial ingrowth did occur, it was diagnosed between eight and 483 days after LASIK. The median amount of time was 110 days. Fairly good treatment The good news about epithelial ingrowth is that “the treatment is fairly good,” said Dr Caster. None of his patients lost best- corrected visual acuity after treatment, which involved lifting the flap and removing the epithelium manually. One person experienced repeat clinically significant epithelial ingrowth, which was diagnosed 166 days later and in a different location from the original ingrowth. During the panel discussion of Dr Caster’s paper, the panellists discussed how concern over epithelial ingrowth has affected the technique they use to perform enhancements. John F Doane MD of Kansas City, who said that he’s “certainly seen the same situation – the further they go out, the greater the risk for epithelial ingrowth,” said that he uses surface enhancement rather than lifting the flap on patients who exceed the one-year mark. Karl G Stonecipher MD of Greensboro, North Carolina, also said that he uses a one- to two-year cut-off for patients with myopia or astigmatism based on the residual refractive error. “If it’s mixed astigmatism or a hyperope, I’ll extend it out to two years,” he said. “After two years, I have found that a transepithelial PRK is as effective in terms of visual outcomes and less risky in terms of potential complications such as epithelial ingrowth in those patients requiring an enhancement procedure. In an interview with EuroTimes, Dr Caster said he was surprised to hear how many people were performing PRK as an enhancement for LASIK due to the risk of epithelial ingrowth. He noted that surgeons were forced to use an “arbitrary” one-year cut-off in the “absence of cold, hard facts.” He said that the results of his study support two possible courses of action. The first would be to enact a three-year cut-off for switching from flap lift to PRK, and the second would be to simply proceed with flap lift despite the increased risk of epithelial ingrowth. Moderator Parag A Majmudar MD, associate professor of ophthalmology at Rush University Medical Center in Chicago, said that he had been using three years as his cut-off based on anecdotal evidence, and was glad to have Dr Caster’s study to back this up. “I think it makes sense [to lift the flap] within one year or two, because you get good results with lifting and it’s much easier than PRK,” he said. Dr Caster said he’s been following the second approach. “I’m still enhancing most of my patients with flap lifts because although I did have a seven per cent ingrowth rate in cases of three or more years after the original LASIK, it didn’t result in any loss of best-corrected visual acuity and only one case had recurrence. I think that the treatment is very effective, and I find that patients like the flap lift much better than the PRK procedure.” info@castervision.com pamajmudar@chicagocornea.com jdoane@discovervision.com stonenc@aol.com 17 Andrew I Caster Lifting flap three years after LASIK increases risk of epithelial ingrowth Refractive Laser 1 Optometry and Vision Science, September 2007 Visit us at Booth F11 at ESCRS Special ESCRS Pricing BFE8EJG<:LC8ID@:IFJ:FG< RECOGNIZED AS THE GOLD STANDARD BY INDUSTRY ORGANIZATIONS.1 30 years of stability, experience and innovation First to market CellChek features: · Increased accuracy · Auto check · Increased reliability Distributors required in some European countries Trade in your old specular microscope at ESCRS booth F11 PO BOX 232, DUNDEE. DD5 2YN, UNITED KINGDOM. TEL: +44 7740877540 For more information about Konan Medical products, visit:nnn%bfeXe%Zfd “I think that the treatment is very effective, and I find that patients like the flap lift much better than the PRK procedure” Andrew I Caster MD

Dermot McGrath in Rome THE femtosecond laser offers several clear advantages for lamellar and penetrating keratoplasty (PK) procedures, according to Emilio Balestrazzi MD, and Luigi Mosca, MD from Catholic University, Agostino Gemelli Polyclinic, Rome, Italy. “The IntraLase femtosecond laser (AMO) is a dynamic surgical tool which enables surgeons to perform valid, safe and repeatable lamellar and penetrating keratoplasty techniques. However, we must nevertheless be cautious in the application of this exciting technology and remember that it is still a work in progress,” Dr Balestrazzi said, presenting their four-year experience with the femtosecond laser in a session of the 13th ESCRS Winter Meeting in Rome. Before the introduction of the femtosecond laser, surgeons could choose between traditional PK and manual deep anterior lamellar keratoplasty (DALK), noted Dr Balestrazzi. While PK has a good track record, the unnecessary substitution of the healthy endothelium results in a life-long risk of eventual graft rejection. By contrast, DALK has the advantage of preserving the endothelium layer and removing only the pathological stromal tissue, thereby preserving normal corneal thickness and shape. There are, however, some drawbacks to DALK, said Dr Balestrazzi, including the difficulty of the manual intrastromal dissection and the fact that the procedure rarely achieves precision and may result in low visual acuity and poor optical quality, if Descemet’s membrane is not reached using the Big Bubble technique. There is also a high risk of micro- or macro- perforation in DALK procedures, often necessitating an eventual conversion to PK. Many of these drawbacks seem to have been addressed by the introduction of femtosecond laser-assisted deep anterior lamellar keratoplasty (femto-DALK) procedures, said Dr Balestrazzi. “For keratoconus patients, the goal is to utilise a surgical option that could be compared in results to manual DALK, preserving the health and integrity of the corneal endothelium,” he said. Describing the new technique they have realised, Dr Balestrazzi said, that there are two distinct surgical phases. The IntraLase femtosecond 60 kHz laser is first used to generate a deep stromal cut, leaving at least 100 µ, based on the pachymetric parameters of the patient. A +4.0 D spherical hyperopic PRK ablation and a 40 to 60 µ PTK ablation are then performed with an excimer laser on the residual stromal bed, to reach as much as possible of Descemet’s layer. The second surgical phase then involves performing the donor cut followed by Descemet/endothelium layer stripping and corneal suturing using 16 radial 10/0 nylon stitches. Dr Balestrazzi and Dr Mosca tested this approach on 16 eyes of 16 keratoconus patients and found that a clear graft was achieved in all patients one week after surgery (Figure 1). The mean uncorrected visual acuity was 0.40 and the mean best-corrected visual acuity was 0.80 at the one-year follow-up mark (Figure 2). Dr Balestrazzi noted that confocal microscopy evaluation showed no significant differences in pre- and postoperative endothelial pattern and density. In terms of complications, two patients experienced a perforation during the IntraLase cut which required a subsequent PK. Turning to femtosecond laser-assisted PK, Dr Balestrazzi said that this technique is designed to create a simpler and repeatable surgical technique to generate less astigmatism, faster wound healing and faster visual recovery times. With more surgeons making the switch to the femtosecond laser, Dr Balestrazzi said that IntraLase-assisted keratoplasty is relatively easy to learn and perform and results in high patient satisfaction (Figure 3). He noted that the femtosecond laser- assisted approach overcomes many of the inherent drawbacks of traditional mechanical corneal transplantation techniques such as delayed visual recovery, high risk of post traumatic wound rupture and the fact that many patients are left with residual postoperative astigmatism because the donor button and the receiving bed are not well aligned. Otherwise, IntraLase-assisted PK has longer operative times. One of the key advantages of the femtosecond- assisted technique is that it allows the user to perform a variety of different cut patterns, customising the surgery to the single clinical case, noted Dr Balestrazzi. Discussing some of the newer cut profiles in more detail, Dr Balestrazzi cited the zigzag-shaped incision developed by Roger Steinert MD in order to provide a smoother transition between host and donor and a hermetic wound seal. This particular cut profile we use routinely in our practice results in an excellent anterior apposition and an extremely smooth graft surface, he said. As well as the Christmas tree wound configuration, which adds more endothelium by increasing the posterior diameter, Dr Balestrazzi said that another interesting variation is the zig cube or zig square incision profile created by Sheraz Daya MD. The zig square offers the same advantages as the zigzag cut with excellent anterior apposition, a watertight incision to protect the endothelium and larger posterior diameter. However, unlike the zigzag cut, the zig square is not positioned as close to the limbus, thereby theoretically reducing the risk of rejection. Dr Balestrazzi concluded that the femtosecond laser is a dynamic and exciting technology that offers a wide variety of corneal therapeutic applications and enables surgeons to perform safe and reproducible lamellar and PK procedures. emilio.balestrazzi@rm.unicatt.it. l.mosca@tin.it 18 Emilio BalestrazziLuigi Mosca Femtosecond laser enhances safety and efficacy of keratoplasty procedures Cornea Update Figure 1: Digital slit lamp photograph. A clear graft is found one week after IntraLase-assisted DALK Figure 3: Slit lamp examination of an IntraLase-assisted penetrating keratoplasty with Mushroom shape for keratoconus, one year after surgery. Note the double diameter of trephination. 11mm for the epithelial and 9mm for the endothelial side Figure 2: IntraLase-assisted DALK on 16 eyes of 16 patients. The graphic shows the UCVA and BSCVA during follow-up. The green star shows the mean suture removal time: a good visual recovery from the first month post-op that rapidly and progressively increase after suture removal Courtesy of Luigi Mosca MD

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Dermot McGrath in Rome POST-PENETRATING keratoplasty (post-PK) glaucoma is one of the leading causes of graft failure, but its incidence may be reduced if clinicians monitor IOP on a regular basis after corneal transplantation and treat aggressively if the pressure is found to be elevated, according to an Indian study. “Post-PK glaucoma is a serious clinical problem because of difficulty in diagnosis and management. Uncontrolled IOP after penetrating keratoplasty is a leading cause of graft failure and visual loss. Despite clear grafts, optimal visual outcome may not be obtained in all patients, so it is mandatory to evaluate IOP on a regular basis and intervene promptly to treat the problem,” Sonika Gupta MD told delegates attending the 13th ESCRS Winter Meeting. Defining post-PK glaucoma as elevated IOP greater than 21 mmHg with or without associated visual field loss or optic nerve head changes, Dr Gupta said that the purpose of her study was to analyse the incidence, risk factors, treatment modalities, graft status and visual acuity outcomes in those patients with glaucoma after PK. The retrospective study carried out at the Government Medical College and Hospital, Chandigarh, India, included 260 eyes of 260 consecutive patients who had undergone PK between 2003 and 2007. The medical records of those patients diagnosed with post-PK glaucoma were reviewed with respect to age, sex, indication for PK, preoperative visual acuity, evidence of existing glaucoma, and use of anti- glaucoma medications and surgeries performed. Dr Gupta noted that the relevant intraoperative data reviewed included the details of the type of surgery, the graft size and also whether the PK was combined with other procedures such as cataract surgery, intraocular lens removal or exchange, secondary IOL implantation or anterior vitrectomy. The postoperative information gleaned from the review included visual acuity data, status of corneal graft, status of anterior chamber, intraocular pressure as measured by Goldmann applanation tonometry and disc evaluation in patients where the lens media was clear. Dr Gupta said that the type of postoperative management – medical therapy, glaucoma filtering surgery, or cyclocryotherapy – was also taken into consideration, as were the final visual outcome and status of the graft. Looking at the overall data, Dr Gupta reported that 30 of the 260 eyes (11.5 per cent) were found to have post-PK glaucoma. The age range was from eight to 76 years and included 20 males and 10 females, with a mean follow-up period of 15 months. The indications for PK in those patients that were diagnosed with post-PK glaucoma included adherent leucoma in 26 per cent, perforated corneal ulcer in 20 per cent, aphakic bullous keratopathy in 20 per cent, infectious keratitis in 17 per cent, failed graft in 10 per cent and pseudophakic bullous keratopathy in seven per cent. Associated aphakia was found in 13 eyes (43 per cent) and an additional surgical procedure had been carried out in seven eyes (23 per cent), including cataract surgery in four eyes and anterior vitrectomy in three eyes. Pre- existing glaucoma was present in six eyes (20 per cent) out of which four eyes had previous glaucoma filtering surgery. The mean graft size was 8.03mm, said Dr Gupta. Of the 30 patients diagnosed with post- PK glaucoma, 18 patients were treated with medical therapy, seven with trabeculectomy and mitomycin C, four with cyclodestructive procedures and one patient with malignant glaucoma was treated with vitreous aspiration and air injection. Looking at the final outcomes, Dr Gupta said that the researchers found a clear graft in only 15 eyes (50 per cent), with a visual acuity of 20/200 or better in eight eyes (27 per cent). In terms of risk factors, she noted that aphakia (with an odds ratio (OR) of 9.71) and associated surgical procedures (OR 2.18) were found to be the most common risk factors in this series. Putting the results in perspective, Dr Gupta said that the study outcomes were broadly in accord with those already published in the scientific literature. She cited a study by Chander et al in the Indian Journal of Ophthalmology which reported a post-PK glaucoma of 27 per cent, and which identified risk factors. Another study by Sihota et al in the Australia and New Zealand Journal of Ophthalmology found an incidence of post-PK glaucoma of 10.6 per cent (79 out of 747 patients), and concluded that a high incidence of post-PK glaucoma occurs in eyes with adherent leucomas. Dr Gupta said that post-PK glaucoma remains one of the most common causes for irreversible visual loss and the second leading cause for graft failure after rejection. dr_sonika2003@yahoo.co.uk 20 IOP after penetrating keratoplasty requires careful monitoring and rapid intervention Glaucoma Update WOC®2010HonoraryPresident ProfessorDr.BruceE.Spivey,ICOPresident WOC®2010ScientificProgramCommittee Chair: ProfessorStephenJ.Ryan Co-Chairs: ProfessorBerndBertram ProfessorGabrieleE.Lang ProfessionalCongressOrganizer MonikaPorstmann PorstmannKongresseGmbH pco@woc2010.de Venue ICCBerlin www.woc2010.org www.dog.org WOC®2010ExecutiveCommittee: President ProfessorGerhardK.Lang SecretaryGeneral ProfessorAnselmKampik Treasurer ProfessorJochenKammann ProgramDirector ProfessorGabrieleE.Lang DOGManagingDirector Dr.PhilipGass WOC®2010Seeyou WorldOphthalmologyCongress®2010 Berlin,Germany XXXIIInternationalCongressofOphthalmology 108thDOGCongress 5-9June2010 AADCongress2010 3-6June2010 InternationalCouncilofOphthalmology(ICO) (Sponsor) GermanSocietyofOphthalmology(DOG) (Host) GermanAcademyofOphthalmology(AAD) (Co-Host)

BARCELONA 2009 XXVII Congress of the ESCRS 12 – 16 September CCIB Congress Centre Barcelona Spain EuropEan SociEty of cataract & rEfractivE SurgEonS Log on to www.escrs.org for: n Programme Information n Registration n Hotel Reservations PROGRAMME HIGHLIGHTS SATURDAy 12 SEPTEMBER 08.30 – 17.00 REFRACTIVE SURGERy DIDACTIC COURSE 09.00 – 16.00 yOUnG OPHTHALMOLOGISTS PROGRAMME Chairpersons: P. Barry IRELAND C. Zetterstrom NORWAY 16.30 – 18.00 VIDEO SyMPOSIUM On CHALLEnGInG CASES Chairpersons: R. Osher USA SUnDAy 13 SEPTEMBER 09.00 – 16.15 WORkSHOP On VISUAL OPTICS Chairpersons: I. Pallikaris GREECE M.J. Tassignon BELGIUM 15.00 – 17.00 JOURnAL OF CATARACT & REFRACTIVE SURGERy SyMPOSIUM Controversies in cataract and refractive surgery Chairpersons: T. Kohnen GERMANY E. Rosen UK MOnDAy 14 SEPTEMBER 10.30 – 11.00 BInkHORST MEDAL LECTURE Super Vision: Myth and Reality I. Pallikaris GREECE

SATURDAy 12 SEPTEMBER 14.00 – 16.00 ESCRS/WCPOS Symposium: Paediatric cataract and refractive surgery Chairpersons: K. Nischal UK P. Rosen UK 14.00 M. Morales SPAIN How reliable is biometry in the child? 14.10 C. Lloyd Uk IOL material for paediatric cataract surgery: Is there any role for PMMA? 14.20 Questions 14.30 C. Zetterstrom NORWAY Anterior and posterior capsulorhexis in children 14.40 A. Levin USA Can we prevent secondary glaucoma post paediatric cataract surgery? 14.50 F. Stegmann SOUTH AFRICA Managing traumatic paediatric cataracts 15.00 Questions 15.10 P. Nucci ITALY LASIK in children 15.20 M. O’Keefe IRELAND PRK and LASEK in children 15.35 Questions 16.00 End of session The World Congress of Paediatric Ophthalmology and Strabismus will take place on Saturday 12 and Sunday 13 September at the CCIB in conjunction with the ESCRS Congress. A joint ESCRS/WCPOS Symposium will take place on Saturday afternoon. For full details of the WCPOS programme, please go to www.wcpos.org SUnDAy 13 SEPTEMBER 11.00 – 13.00 Managing Subluxated Lenses Chairpersons: K. Krootila FINLAND D. Spalton UK 11.00 T. Moore UK New insights into ectopia lentis 11.15 A. Vasavada INDIA Surgical correction of ectopia lentis 11.30 U. Stenevi SWEDEN Incidence and prognosis of IOL subluxation after routine surgery 11.45 A. Crandall USA Repositioning of displaced IOLs 12.00 S. Masket USA Scleral suturing techniques 12.15 G. Grabner AUSTRIA Anterior chamber lenses in the management of subluxated lenses 12.30 Questions and answers 13.00 End of session MOnDAy 14 SEPTEMBER 11.00 – 13.00 Cataract and Macular Disease Chairpersons: A. Augustin GERMANY J. Cunha-Vaz PORTUGAL 11.00 C. Lobo PORTUGAL Diagnosis and management of post-surgical macular edema 11.15 U. Schmidt-Erfurth AUSTRIA A review of the role and efficacy of anti-VEGF therapy in macular disease 11.30 S. Scholl GERMANY Cataract surgery in patients with pre-existing AMD: Risks and benefits 11.45 G. Richard GERMANY Combined cataract and vitreoretinal surgery 12.00 S. Rizzo ITALY Cataract surgery in patients with diabetic retinopathy – risks and benefits 12.15 M.J. Tassignon BELGIUM Cataract surgery and intraocular low-vision aids 12.30 Questions and answers 13.00 End of session TUESDAy 15 SEPTEMBER 11.00 – 13.00 Cross-Linking Chairpersons: J. Colin FRANCE D. Epstein SWITZERLAND 11.00 J. Marshall UK Physiological and therapeutic cross-linking 11.15 J. Hjortdal DENMARK Biomechanics of the crossed-linked cornea 11.30 P. Vinciguerra ITALY Technique intra-operative findings and postoperative regimen 11.45 F. Raiskup-Wolf GERMANY Results of cross-linking in keratoconus and iatrogenic ectasia 12.00 D. Touboul FRANCE Combining cross-linking with intracorneal segments 12.15 T. Seiler SWITZERLAND Results of cross-linking for corneal melting disorders 12.30 Questions and answers 13.00 End of session WEDnESDAy 16 SEPTEMBER 11.00 – 13.00 Surgical Solutions for High Refractive Errors Chairpersons: Z. Biro HUNGARY J.L. Guell SPAIN 11.00 R. Navarro SPAIN Myopia from a retinal point of view 11.15 D. Reinstein UK LASIK for high myopia: New considerations 11.30 B. Cochener FRANCE Phakic IOLs for high ammetropia: An update 11.45 J.L. Alio SPAIN Refractive lensectomy update 12.00 I. Pallikaris GREECE Combined refractive surgery 12.15 F. Malecaze FRANCE Genetics and high myopia: Therapeutic considerations 12.30 Questions and answers 13.00 End of session MAIn SyMPOSIA BARCELONA 2009 XXVII Congress of the ESCRS

CLInICAL RESEARCH SyMPOSIA SATURDAy 12 SEPTEMBER 08.30 – 17.00 08.30 – 10.00 Wound-healing aspects of contemporary corneal surgery Chairpersons: F. Malecaze FRANCE J. Murta PORTUGAL 08.30 To be confirmed KEY LECTURE: New concepts in wound healing after refractive corneal surgery: New prospects for therapy 08.50 F. Majo SWITZERLAND Corneal epithelial stem cells don’t sleep in the limbus 09.05 To be confirmed Early corneal wound healing in corneal lamellar surgery 09.20 M. J. Quadrado PORTUGAL Confocal microscopy as an evaluation tool of wound healing in corneal surgery 09.35 N. Knox Cartwright UK Biomechanical analysis of collagen crosslinking treatment 09.50 Discussion 10.00 End of session 10.00 – 11.30 new concepts of accommodative IOLs Chairpersons: P. Sourdille FRANCE M. Tetz GERMANY 10.00 J. Coleman USA Accomodation mechanisms and new imaging 10.15 J.M. Parel USA Accomodation measurements 10.30 P. Sourdille FRANCE IOLs anatomical prerequisites for accommodation 10.45 A. Glasser USA Subjective and objective measurement of accommodation in phakic and pseudophakic eyes 11.00 T. Terwee USA To be confirmed 11.15 Discussion 11.30 End of session 11.30 – 13.00 ESCRS/ARVO Symposium: The impact of refractive surgery on corneal structure This symposium sponsored by ARVO highlights the basic and clinical understanding of corneal structure from its anterior to posterior segments with special focus on the impact of various refractive surgeries. Chairperson: S. Kinoshita JAPAN P. Rosen UK 11.30 S. Kinoshita JAPAN Introduction 11.32 F. Kruse GERMANY Corneal nerve and epithelium in refractive surgery 11.45 K. Meek UK Corneal shape supported by collagen organization 12.00 D. Tan SINGAPORE Corneal stromal effects and profiles with deep femtosecond laser ablations 12.15 Y. Rabinowitz USA Is keratoconus genetic? Why is it important for the refractive surgeon? 12.30 F. Hafezi SWITZERLAND Collagen cross-linking therapy 12.45 S. Kinoshita JAPAN Corneal endothelium in refractive surgery 12.58 P. Rosen UK Summary and conclusions 13.00 End of session 14.00 – 15.30 Surgical control of astigmatism Chairpersons: J.L. Alio SPAIN T. Olsen DENMARK 14.00 R. Albertazze ARGENTINA Intracorneal ring segments 14.15 J.L. Alio SPAIN Toric IOLs 14.30 N. Alpins AUSTRALIA Astigmatism analysis 14.45 G. Auffarth GERMANY Astigmatic control with toric IOLs 15.00 G. Kymionis GREECE Astigmatic keratotomy with the femtosecond laser 15.15 F. Carones ITALY Excimer correction of astigmatism 15.30 End of session 15.30 – 17.00 Perfect optics: Ocular light scattering Chairpersons: D. Spalton UK M.J. Tassignon BELGIUM 15.30 H. Ginis GREECE The physics of light scattering 15.42 T. van den Berg THE NETHERLANDS Light scattering in the human eye 15.57 J. Rozema BELGIUM Ocular biometry and straylight 16.09 P. Artal SPAIN Measurement of light scattering in vivo 16.24 D. Spalton UK Clinical experience with the OQAS 16.36 J. Colin FRANCE Measurement of light scattering from IOL glistenings 16.48 Discussion 17.00 End of session XXVII Congress of the ESCRS 12 – 16 September 2009 12 – 16 September

During the XXVII Congress of the ESCRSCCIB Congress Centre, Barcelona, Spain Congress Venue General Information Keynote Lectures CCIB (Centre de Convencions Internacional de Barcelona), Rambla Prim 1-17, 08019 Barcelona, Spain Jack Kanski UK Uveitis in Juvenile Idiopathic Arthritis Saturday 12 September 12.00 – 12.40 Ken Wright USA Innovations in the Management of Strabismus Sunday 13 September 12.00 – 12.40 12–13 September 2009 World Congress of Paediatric Ophthalmology and Strabismus Online registration and hotel booking now available www.wcpos.org WCPOS Lunchtime Symposia (lunchbox included) Saturday 12th September 13.00 – 14.00 ROP in 2009: Regional Solutions for Preventable Childhood Blindness Room: 133 n Review the characteristics of successful ROP programs in different areas of the world n Examine practical solutions to plan and implement an ROP management program n Understand the differences between indirect ophthalmoscopy and digital photography in screening for Retinopathy of Prematurity n Learn how to create an ROP screening telemedicine network Sponsored by Sunday 13th September 13.00 – 14.00 Managing Ocular Diseases in Paediatrics Room: 111 Moderator: E. Silva PORTUGAL E. Silva PORTUGAL Ocular surface infection: diagnosis and treatment in paediatrics J. Montero SPAIN Palpebral infectious disorders: diagnosis and treatment T. Karcher GERMANY Dacryocystitis management D. Bremond Gignac FRANCE Azyter, the first 3-day ocular antibiotic treatment Sponsored by

08.00 09.00 10.00 11.00 12.00 13.00 14.00 15.00 16.00 17.00 18.00 08.00 09.00 10.00 11.00 12.00 13.00 14.00 15.00 16.00 17.00 18.00 19.00 Programme Overview Saturday 12 September Sunday 13 September Room 112 Room 111 Room 133Room 112 Room 111 Room 133 Opening & Welcome Free Papers (Non Strabismus) Ch: David Granet Ch: Ken Nischal Free Papers (Strabismus) Ch: David Granet Ch: Ken Nischal Strabismus Syndromes Ch: Ramesh Kekunnaya Ch: Cumhur Sener LIDS Ch: Dominique Bremond Ch: Chang, Hae Ran Optic Neuritis in Children Ch: Paul Phillips Early Intervention and Rehabilitation of Children with Impaired Vision Ch: Lea Hyvarinen Paediatric Anaesthesia Ch: Richard Martin Application of Telemedicine Ch: Thomas France Strabismus Re-do Strategies Ch: Steve Kraft Paediatric Glaucoma Ch: Alicia Serra-Castanera Ch: Nicola Freeman Satellite Meeting Clarity Medical Systems ROP in 2009: Regional Solutions for Preventable Childhood Blindness Satellite Meeting Laboratoires THEA Managing Ocular Surface Infection in Paediatrics Paralytic Strabismus Ch: Andrea Molinari Ch: Julio Yanguela Managing IIH Ch: Grant Liu Managing ONG Ch: Grant Liu Paediatric Uveitis Ch: Clive Edelsten Paediatric External Diseases Ch: Yee Fong Choong Thyroid Eye Disease Ch: David Granet Non-Accidental Injury Ch: Alex Levin Strabismus Techniques Ch: Doran Neumann Genetics Ch: Eduardo Silva Ch: Elias Traboulsi Close of Congress: My World, My Way Ch: Marilyn Miller Keynote Lecture Jack Kanski Keynote Strabismus Lecture Ken Wright Closing Reception Drinks BreakBreak Break Paediatric Retinal Disease (Medical) Ch: Tony Moore Paediatric Retinal Disease (Surgical) Ch: Mangat Dogra Controversies (Amblyopia) Ch: Jonathan Holmes Controversies (Nystagmus) Ch: Richard Hertle EDTs Ch: Alki Liasis 14.00-16.00 Joint Symposium with ESCRS “Paediatric Catract & Refractive Surgery” Chairpersons: Ken Nischal, Paul Rosen Venue: Main Auditorium ROP Ch: Andrea Zin The Orbit Ch: Yassir Abou-rayyah Ch: James Katowitz Retinoblastoma Ch: Brenda Gallie Ch: Arun Singh Exotropia Ch: Zhao Kanxing Ch: Scott Olitsky Esotropia Ch: Seyhan Özkan Ch: Alicia Galan Please note: For ESCRS Scientific Programme, go to www.escrs.org 12–13 September 2009, Barcelona, Spainwww.wcpos.org

BARCELONA 2009 XXVII Congress of the ESCRS 12 – 16 September 2009 Saturday 12th September 13.00 – 14.00 Ziemer REFRACTIVE Symposium: FEMTO LDV™ and GALILEI™ in the State-of-the-Art Refractive Practice Room:113 Moderator: T. Seiler SWITZERLAND Sponsored by 13.00 – 14.00 Improving Patient Outcomes with Advanced Laser Vision Correction Technology Room: 114 Moderators: M. Knorz GERMANY, J. Alió SPAIN M. Wevill UK Mechanical vs Laser Flap Creation: Results of More Than 20,000 Cases S. Schallhorn USA Patient Satisfaction and Visual Outcomes with Wavefront-Guided Femtosecond LASIK: Analysis of More Than 20,000 Cases L. Probst USA Multicenter Comparison of Visual Acuity between Wavefront-Optimised and Wavefront-Guided Ablations J. Stevens UK New Technology and Concepts to Increase Success with Laser Vision Correction Sponsored by 13.00 – 14.00 Meeting patient expectations Room: 118 Moderator: R. Osher USA O. Findl AUSTRIA Optimising premium lens surgery with the IOLMaster R. Osher USA AT LISA toric: preliminary data (3 months follow-up) from the multicentric study R. Zaldivar ARGENTINA Why my patients are simply happier with the AT LISA / AT LISA toric IOL M. Perez FRANCE Intra operative toric IOL alignment system; an effective and reliable new solution Sponsored by 13.00 – 14.00 What will you do? A video panel discussion on challenging and Nightmarish cases in cataract surgery Room: 120 Moderator: A. Agarwal INDIA Speakers: R. Lindstrom USA, J. Alio SPAIN, K. Mehta INDIA, S. Lane USA, S. Masket USA Sponsored by: 13.00 – 14.00 Quantity & Quality of Vision: Optimising Outcomes with Premium IOLs Room: 122 Moderator: B. Cochener FRANCE G. Marchini ITALY Crystalens HD™ Clinical Outcomes E. Mertens BELGIUM How to Provide a Premium IOL Service with the Crystalens HD™ S. Slade USA US experience with the Crystalens HD™ V. Pfeifer SLOVENIA Introducing the Akreos® Toric: The Astigmatism-Correcting Lens Sponsored by Lunchtime Symposia (lunchbox included) EUROTIMES ESCRS ™ SATELLITE EDUCATION PROGRAMME Register online www.escrs.org

Lunchtime Symposia (lunchbox included) FREE TO ALL DELEGATES Sunday 13th September 13.00 – 14.00 Novel Approaches to Managing Patient Refractive Errors Room: 117 Moderator: F. Carones ITALY Faculty: B. Fisher USA, L. Cadarso Suárez SPAIN, M. Knorz GERMANY Sponsored by 13.00 – 14.00 Latest Trends in Dry Eye Room: 114 Moderator: J. Benítez del Castillo SPAIN M. Rolando ITALY New Classification of Dry Eye J. Benítez del Castillo SPAIN Dry Eye and Ocular Surgery J. McCulley USA New treatments of dry eye (I) E. Messmer GERMANY New treatments of dry eye (II) Sponsored by 13.00 – 14.00 Antibiotic Prophylaxis in Cataract Surgery: Revision and Prospects Room Name: 113 Moderator: R. Abbott USA A. Urtti FINLAND Ocular Pharmacokinetics J. Szaflik POLAND A broader perspective: Levofloxacin use in conjunctivitis and ophthalmic surgery S. Barrett UK Microbiology, levofloxacin spectrum and resistance data R. Abbott USA Levofloxacin – revision and prospects Sponsored by 13.00 – 14.00 Experience with the HOYA AF-1 platform Room: 118 Moderator: S. Walter GERMANY M. Vignanelli SWITZERLAND Two years follow up with HOYA AF-1 lenses L. Werner USA Correct Vision: Evaluating and defining the sharpness of IOLs G. Montefiore FRANCE Mini-Incision with the HOYA preloaded system. Why did I choose it? S. Walter GERMANY Comparison of two intraocular lenses. HOYA AF-1 (UV) VA-60BB versus AF-1 (UY) YA-60BB results 3 years after surgery Sponsored by 13.00 – 14.00 Rayner Satellite Meeting Room: 120 Sponsored by 13.00 – 14.00 Leading Technology in Refractive Surgery Room: 122 Sponsored by EUROTIMES ESCRS ™ SATELLITE EDUCATION PROGRAMME

BARCELONA 2009 XXVII Congress of the ESCRS 12 – 16 September 2009 Monday 14th September 13.00 – 14.00 Torsional Technology: New Innovations in Surgical Efficiency Room:117 Moderator: A.Vasavada INDIA Faculty: R. Lorente SPAIN, I. Prieto PORTUGAL, C. Johansson SWEDEN Sponsored by 13.00 – 14.00 Ophthalmic Innovations: What’s New in Refractive Cataract Surgery in 2009? Room: 113 Moderators: J. Güell SPAIN, A. Brézin FRANCE J. Colin FRANCE Advancements in IOL Optics, Material and Design M. Packer USA Targeting Spherical Aberration Correction in Cataract Surgery G. Auffarth GERMANY Optimising Cataract Surgery Safety with New Phaco Technology A. Scheider GERMANY Defining a Customised Surgical Procedure for Multifocal Lenses Sponsored by 13.00 – 14.00 The Future of Refractive Surgery- INTRACOR™ and PresbyLasik for Presbyopia and New ZYOPTIX® Personalized Treatment Advanced Room: 114 Moderator: S. Slade USA Expand your patient range with presbyopia correction M. Holzer GERMANY INTRACOR™ First flapless intrastromal presbyopia correction with the INTRACOR™ workstation - personal experience and CE study results. CE approval April 2009. J. Castanera SPAIN PresbyLasik The new ZYOPTIX® excimer laser algorithm for presbyopia correction - personal experience and CE study results Upgrade your patients to premium procedures to improve their quality of life E. Mertens BELGIUM ZYOPTIX® Personalised Treatment Advanced The new and only algorithm that corrects low and high order aberration without inducing spherical aberration - personal experience and clinical study results E. Mertens BELGIUM ZYOPTIX® Tissue Saving Hyperopia The only algorithm exclusively designed to save tissue in hyperopia - personal experience and clinical results Sponsored by 13.00 – 14.00 Glaucoma Management: Long-Term Experience with Selective Laser Trabeculoplasty Room: 118 Moderator: J. Garcia Feijoo SPAIN L. Jindra USA Long-Term Efficacy of Repeat SLT Treatment: Seven Years’ Follow-Up P. Kaulen GERMANY Seven Years’ Results with SLT J. Martínez de la Casa SPAIN The Spanish Experience With SLT M. Nagar UK My Seven Years’ Experience with Selective Laser Trabeculoplasty as Primary Therapy Sponsored by 13.00 – 14.00 Rayner Satellite Meeting Room:120 Sponsored by 13.00 – 14.00 Novel Perspectives on Ophthalmic Surgical Techniques and Therapy Options Room: 122 Sponsored by Tuesday 15th September 13.00 – 14.00 STAAR Satellite Meeting Room:113 Sponsored by Lunchtime Symposia (lunchbox included)

European Registry of Quality Outcomes for Cataract & Refractive SurgeryEUREQUO The European Registry of Quality Outcomes in Cataract and Refractive Surgery EUREQUO Session Monday 14 September, 2009 Time: 14.30 - 16.00 Room 113 Chairperson: P. Barry, Ireland This project, jointly funded by the European Union and the ESCRS aspires to register every cataract and refractive procedure performed in the 16 participating countries. The pilot countries will share their teething experiences and the professional IT company will show you the back up and assistance available to get you started and keep you going. By demonstrating the results of your surgery you can market your business, win contracts and provide truly informed consent. From university departments to solo practitioners the benefits are there so come and see what is available to you! Instructional Course Monday 14 September, 2009 Time: 08.00 - 10.00 Course no. 67 “EUREQUO for improving my outcomes” There is no charge for this course. See instructional courses for details. Visit the EUREQUO booth & team There will be a special information session every day at 2pm at the EUREQUO booth on how to enter data in the system, reporting on outcomes and benefits of participating. Do not miss this opportunity to become part of the future. If auditing results and registering performance is not mandatory in your practice and your country it soon will be! Take this opportunity to learn how to prepare for it and come and see the benefits to be gained by you. Funded by FREE TO ALL DELEGATES 29 Saturday 12th September Registration: 18:00 - 18:30 Live Surgery Telecast: 18:30 - 20:30 Cataract & Refractive Live Surgery Room: Main Auditorium Host Surgeon: J. Güell SPAIN – FROM THE INSTITUTO MICROCIRUGIA OCULAR DE BARCELONA Moderator: D. Allen UK Surgical Faculty: B. Aslan TURKEY, R. Lorente SPAIN, O. Moraru ROMANIA, K. Tjia THE NETHERLANDS Faculty Panel: F. Carones ITALY, A. Cummings IRELAND, M. Knorz GERMANY, S. Masket, USA D. Serafano USA Sponsored by Sunday 13th September 18:15 Innovations in Advanced Lens Technologies Moderator: T. Kohnen GERMANY Faculty: J. Alfonso SPAIN, B. Fisher USA, R. Nuijts THE NETHERLANDS, R. Osher USA, T. Amzallag FRANCE Sponsored by Monday 13th September 18:15 The 4th MICS™ Symposium: Real Cases & Future Trends Room: 117 Moderator: B. Malyugin RUSSIA B. Dick GERMANY Clinical Benefits of 1.8mm B-MICS versus Standard Phaco P. Viola ITALY Learning MICS: A Resident’s Perspective D. Elies SPAIN 1.8mm C-MICS in Complicated Cases A. Agarwal INDIA The Future of MICS: How Small Can We Go? Sponsored by Evening Symposia EUROTIMES ESCRS ™ SATELLITE EDUCATION PROGRAMME Register online www.escrs.org

EuropEan SociEty of cataract & rEfractivE SurgEonS 2010 14th ESCRS Winter Meeting February 12-14, 2010 The Corinthia Hotel, Budapest, Hungary In association with the Hungarian Society of Cataract and Refractive Surgeons (SHIOL) www.escrs.org

Roibeard O’hEineachain in Berlin A SINGLE intracameral injection of triamcinolone acetonide can safely and effectively control postoperative inflammation in uveitic eyes that have undergone cataract surgery, according to Marko Hawlina MD, PhD, University Eye Hospital, Ljubljana, Slovenia, with co-authors Nataša Vidovic-Valentinčič, MD, Petra Schollmayer, MD and Aleksandra Kraut, MD. In a study involving 12 cataract patients with uveitis of different aetiologies who underwent intracameral injection of triamcinolone at the end of phacoemulsification, all eyes remained quiet throughout the early postoperative period, and there were no pressure spikes and no toxic effects, he reported. The uveitic conditions in the patients’ eyes included two cases each of sarcoidosis panuveitis, TBC panuveitis, and idiopathic panuveitis. There was also one case each of herpetic kerato-uveitis, anterior uveitis with epidermolysis bullosa, and Fuchs’ cyclitis/glaucoma. There were three cases of idiopathic anterior uveitis. All eyes in the study underwent intracameral injection of triamcinolone at the conclusion of phaco-emulsification and implantation of an AcrySof IOL (Alcon). Five patients also underwent systemic administration of 0.5 mg/kg methyl prednisolone, and seven patients received no systemic treatment. Dr Hawlina divided the patients in the study into two dosage groups. One group received a 2.0mg (0.05ml) dosage of triamcinolone and the other group received a 1.0mg (0.025ml) dosage, resuspended in original volume of BSS. The procedures were performed using topical and intracameral anaesthesia. Additional procedures included synechiolysis in 12 cases, iris stretching in 10 cases, peeling of the fibrous rim of the iris in three cases. In addition, iris retractors were used in two cases and intracapsular tension rings were used in three. “Cataract surgery in eyes with uveitic conditions is more traumatic because it requires more manipulation of the iris. The intraoperative trauma sets in motion an arachidonic acid cascade and increases production of prostaglandins and leukotrienes. This can in turn result in inflammation, fibrin formation, miosis, secondary synechiae and cystoid macular oedema,” Dr Hawlina said. Eyes quiet on first day In both dosage groups, all eyes were quiet on the first postoperative day and there was a mean cell count of 1+ cells and no fibrin formation in the anterior chamber. Triamcinolone had largely cleared from the anterior chamber on the first postoperative day and had disappeared completely within one week, in the 1.0mg dosage group, and within four weeks, in the 2.0mg dosage group. There were some cases with corneal deposits of triamcinolone in the 2.0mg group on the first postoperative day. In addition those that received the anti-inflammatory agent as monotherapy remained as quiet throughout the early postoperative period as those that received the agent in addition to systemic administration of methyl prednisolone. Dr Hawlina noted that cataract surgery in uveitic eyes using steroids will generally produce good results. However, a large proportion of patients have inflammation-related complications later on. He noted that in a study he conducted previously in which he followed a population of uveitis patients for five years after cataract surgery, around 10 per cent developed cystoid macular oedema and around 10 per cent developed secondary synechiae. The conventional prophylaxis against postoperative inflammation in uveitic eyes 0.5-1mg/kg oral methyl prednisone to the baseline treatment five days before surgery and then tapering the dosage to baseline levels during the first three postoperative days. However, there are now several published studies showing that triamcinolone may achieve a superior result. In one study, a single intravitreal injection of 4.0mg of triamcinolone provided a more effective prophylaxis against reactivation of inflammation and cystoids macular oedema than oral steroids and there were no local or systemic side effects from the agent (Dada et al, JCRS 2007;33:1613-8). In another study, the same dosage of triamcinolone administered intracamerally resulted in less postoperative fibrin formation, cystoids macular oedema and hypotony than occurred with intravenous or oral steroids in cataract patients with juvenile idiopathic arthritis and uveitis (Li et al, JCRS 2006 ;32(9):1535- 9). “From our study it appears that a single intracameral injection of 0.02ml triamcinolone acetonide is sufficient to control postoperative inflammation in the immediate postoperative period in cases of uveitis,” Dr Hawlina added. marko.hawlina@mf.uni-lj.si 31 Triamcinolone crystals suspended in anterior chamber with larger dose used (2mg TA = 0.05ml) immediately after the operation (left) and first postoperative day (right). No uncontrollable pressure spikes were noted with the highest of 28 mmHg Suspended triamcinolone in anterior chamber and in lower portion of angle (1mg TA = 0,025ml) one hour after the operation (left) and first postoperative day (right) in an eye with herpetic keratouveitis Courtesy of Marko Hawlina MD, PhD Intracameral triamcinolone provides good control postoperative inflammation in uveitic eyes Retina Update Marko Hawlina Toapply,callDavidCarsonon+44(0)1236723300/+44(0)7771930423. Alternativelye-mail:davidcarson@opticalexpress.comorwriteto OpticalExpress,5DeerdykesRoad,Westfield,Cumbernauld,G689HF,UnitedKingdom. OpticalExpressisnowrecruitinglaserandintraocularsurgeonstotreatin ourstate-of-the-artclinics. IneachofourclinicsweusetheworldleadingVISXS4IRlaserplatformwith AdvancedCustomVueWavefronttechnology,IntraLase femtosecondlaser.Ourstate-of-the-artdiagnosticequipment includesOculusPentacam,ZeissVisanteOCTandthelatest generationofphacoinstruments. 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The 2010 World Ophthalmological Congress (WOC) will be held in Berlin, Germany from June 5 - 9 next year. In this interview, Colin Kerr, executive editor EuroTimes, the official media partner for the congress, talks to WOC 2010 president Prof Gerhard Lang about the plans to make WOC 2010 an outstanding success. ET: Explain the significance of choosing Berlin as the venue for WOC 2010? Prof Lang: This is the third time that the DOG (German Society of Ophthalmology) will host this prestigious international meeting with Berlin following in the footsteps of Heidelberg (1888) and Munich (1966). The DOG and the AAD (German Academy of Ophthalmology) congresses will also take place under the umbrella of the World Congress in Berlin. The International Council of Ophthalmology (ICO) are the sponsors of WOC and every two years they award the hosting of the WOC, which is usually held in a different continent on each occasion. In recent years the congress has been held in Sydney, Australia (2002) Sao Paolo, Brazil (2006) and Hong Kong, China (2008) so now it is Europe’s turn. We were awarded the Congress in 2002 and we have been preparing for it for the last seven years. As the old and new capital of Germany, we believe that Berlin is a unique link between Eastern and Western Europe thus representing the ideal location for the WOC® 2010. It is an exciting city with a unique culture, history and architecture and we believe this will be a major attraction for delegates who will come from all over the world to attend the congress. ET: What is your message to delegates from Eastern Europe who will have a unique opportunity to meet with their colleagues 20 years after German reunification? Prof Lang: The DOG was always internationally oriented and Eastern European countries have symposia at the DOG meetings on a regular basis for many years. At the last DOG meetings we were able to welcome delegates from more than 90 countries. Berlin, in the heart of Europe, is easy to reach by car, bus or short flights from everywhere in Europe, especially East Europe. ET: There have been major advances in ophthalmology in German society since reunification in the last 20 years and there have also been major advances in the world of ophthalmology. How will WOC 2010 in Berlin reflect these changes? Prof Lang: A brilliant scientific programme is crucial for the success of a meeting. Supranational and national societies will organise symposia and subspecialty days devoted to glaucoma, cataract surgery, retina and refractive surgery. We will have delegates attending and presenting from all over the world and I am looking forward to hearing the different perspectives ET: The World Congress in Berlin will give delegates the opportunity to reflect on the old and new Germany, but also the changes in ophthalmology that are being led by a new generation of ophthalmologists. How will the congress reflect these changes? Prof Lang: Next year in Berlin delegates will get the opportunity to hear from the opinion leaders, the stars of ophthalmology, but we also want young ophthalmologists to submit papers and take part in the symposia and scientific sessions and also in the instruction courses which are a very important part of the programme in Berlin. ET: What are the major challenges facing ophthalmologists in 2010 and how will the World Congress address these challenges? Prof Lang: There is no better place than a World Ophthalmology Congress to focus on the current state and future of our profession. WOC 2010 will raise awareness of the disparity of eye care between industrialised and developing countries and we will also be seeking to intensify international cooperation. In Europe a major challenge for ophthalmologists is reimbursement as new services and technologies are not always accompanied by an increase in fees but this is obviously not the case in other regions. WOC 2010 will give us an opportunity to look at different models of modern practical management of patient care and WOC 2010 is the perfect stage to pass on our perspectives on these issues. We must also not forget to use our skills, knowledge and teaching to help those in underdeveloped countries with the right action plans and this will be one of the key themes of the congress. ET: One of the major highlights of the WOC is the opening ceremony which reflects the unique cultural heritage of the host city. What can we look forward to in Berlin next year? Prof Lang: The Opening Ceremony on Saturday June 5 will have many surprises and is definitely not to be missed. The WOCtoberfest which takes place on Monday June 7 will be an original Bavarian- style “Octoberfest” with typical music, entertainment, food and beer and also non- alcoholic and vegetarian options. At this point, we are inviting all delegates and their families to wear their national attire or traditional costume to this event, to celebrate this truly international occasion. ET: What are your plans for the exhibition which will be one of the highlights of WOC 2010? Prof Lang: The exhibition will provide an excellent overview of new developments and products. This is a very important feature of the congress because it gives delegates an overview of the products that are on the market and the new technologies that are coming to the market. At WOC 2010, delegates will be able to attend lectures and hear about a new machine and device and then after the lecture they can go to the exhibition and find out more information. ET: What else can delegates look forward to at WOC 2010? Prof Lang: We will also work to ensure that every delegate finds what he or she wants – top-line research, comprehensive ophthalmology, instructional courses, wet labs, refreshers, overviews, video programme and posters or keynote lectures by ophthalmological celebrities and field leaders. With three meetings under one roof (AAD, DOG and WOC) it is also a great opportunity for continuing medical education. The AAD programme (June 3 – 6) and part of the DOG programme will be presented in German language and simultaneously translation in certain halls is planned. ET: Please discuss the collaboration with EuroTimes and its importance for WOC 2010? Prof Lang: We have chosen EuroTimes as our official media partner and I am looking forward to our cooperation together. EuroTimes is a modern journal with a worldwide distribution which will help us to highlight the scientific programme of WOC 2010 and also inform delegates about “what else there is to do in Berlin and Germany. In EuroTimes, we will provide more congress-specific information over the next year and during the congress delegates will also be able to find out what is going on in the special EuroTimes newsletter ET Today which will be distributed to delegates. ET: How can people learn more about WOC 2010 and the Berlin meeting? Prof Lang: The best source, in addition to EuroTimes, is our website www.woc2010. org with links to the DOG (www.dog.org) the AAD (www.aad.to) and ICO (www.icoph.org) homepages. ET: Every congress has a different atmosphere and spirit. What do you hope will be the special spirit of WOC 2010? Prof Lang: In 1857 Albrecht von Graefe founded the oldest ophthalmological society of the world – the DOG, just before the German ophthalmologists went to the first International Congress of Ophthalmology in Brussels. Twenty years after reunification we are proud to show Berlin as it is now with the old architecture and history but also as a modern European centre which is the shooting star of European cities. As the old and new capital of Germany, we believe that Berlin is a unique link between Eastern and Western Europe thus representing the ideal location for the WOC 2010. It is an exciting city with a unique culture, history and architecture and we believe this will be a major attraction for delegates who will come from all over the world to attend the congress. pco@woc2010.de 33 WOC 2010 will bring eastern and western Europe closer together Ocular Update Gerhard Lang eTIMES is EuroTimes’ bimonthly newsletter with the latest breaking news from the ESCRS and the world of ophthalmology. We offer exclusive access to upcoming EuroTimes content where subscribers can read our stories first online. To subscribe to this exciting new service log on to the EuroTimes website at www.eurotimes.org.

OPHTHALMOLOGISTS have reached a defining moment in the history of their discipline not only because there are so many new possibilities for diagnosis and therapy offered by new discoveries in molecular and cell biology, but also because the world’s ageing population means that there will be a greater number of people than ever before with sight-threatening diseases. Prof Eberhart Zrenner MD, director of the Institute for Ophthalmic Research and the Centre for Ophthalmology and head of the Neuro-ophthalmology unit in Tuebingen Germany, discussed these issues when he presented the EURETINA lecture at the 9th EURETINA Congress in Nice France. Prof Zrenner is also chairman of the European Vision Institute. In his presentation, which sought to answer the question, “Can We Overcome the Fragmented European Research Space in Ophthalmology?” Prof Zrenner said that the ability of ophthalmology to answer that question is compromised by the fragmentary nature of ophthalmic research in Europe, and by the lack of awareness among healthcare policy makers of the contribution ophthalmic research can make, and of the dire consequences that will likely occur if that field of endeavour is neglected due to lack of funds. He noted that there are more than 40 national and international ophthalmological associations in Europe and said that while those organisations are essential for the continuity of clinical research, what is lacking is an organisation to provide a single voice to defend the interests of ophthalmological research before the EU. “The result of this plethora of ophthalmic societies is a low impact of ophthalmology in the making of research policies. We have a low visibility compared with other areas, like neuroscience oncology or vascular sciences. There is a lack of structured proposals that will enable us to get enough money to form huge networks working together on European-wide trials,” Prof Zrenner said. Another type of fragmentation that occurs in ophthalmic research is a lack of communication between those engaged in basic science inspired by clinical findings in ophthalmological practice and those engaged in clinical research. “The challenge is really to improve our acceptance of vision research among the scientific community; we are not just a little eye which may be a part of the brain, we are more and we can make that point only if we speak with a loud voice and in a harmonised, focused manner in order to avoid fragmentation. We have to avoid duplication of research with multiple small trials examining identical issues instead of one large trial. We also have to merge the two cultures of basic science on the one hand and clinical science on the other,” Prof Zrenner said. To that end Prof Zrenner and his associates have founded the European Vision Institute, an organisation whose aim is to lobby for research funding for ophthalmology, establish study protocols, and foster collaboration between different research organisations. The fruits of their labour so far include EVI-Genoret and RETNET, projects investigating the genetic factors of retinal disease. More recently they have obtained funding for and have established Eurovisionet which aims to provide a scientific integration of European vision research and have established an online portal to which all engaged in ophthalmic research can contribute. “Yes, we can overcome the fragmented nature of ophthalmic research in Europe if we want to and we get together.” In presenting Prof Zrenner with his EURETINA lecture award, EURETINA co-founder and general secretary Gisbert Richard MD noted that the Clare Jung foundation that sponsors the award do so because they are convinced that the greatest success in fighting blindness will be found in the field of retina and optic nerve research. ALMOST 1,700 delegates attended the 9th EURETINA Congress in Nice, the biggest attendance at any congress in the history of the society. In his opening speech at the European Society of Retina Specialists (EURETINA) opening ceremony the president of EURETINA, Prof José Cunha-Vaz MD, expressed his satisfaction with the growth of the society and the continuing improvement of the congress from year to year. “I am particularly pleased with the way our society has expanded and that it is offering participants what they want and we would like to continue going in that direction. Bill Aylward from the UK, who will assume the presidency next year, will certainly carry that work further with even better congresses,” he said. Dr Cunha-Vaz credited the congress organisers Agenda with making the congress run more smoothly and efficiently. He noted that in a move to integrate the different fields of ophthalmology next year’s EURETINA meeting will be held in Paris directly before and at the same venue as the Annual Congress of the European Society of Cataract and Refractive surgeons (ESCRS). “The fact that the largest subspecialty societies are coming together will be an impressive opportunity for the industry and for anterior and posterior segment surgeons to gain more exposure to each other’s disciplines. He noted that EURETINA has recently signed an agreement for Ophthalmologica, one of the oldest and most prestigious European scientific journals in ophthalmology to become the society’s official scientific journal. Starting in 2010, it will have Prof Cunha-Vaz as its editor in chief. “This is something we can offer our members to allow us to express our scientific studies and somehow create a better, solid basis for our scientific development, he said. 9th EURETINA CongressNICE Overcoming the fragmented research space in ophthalmology Record attendance at the 9th EURETINA Congress Dr Eberhart Zrenner (pictured left) receives his award after presenting the 2009 EURETINA Lecture from Gisbert Richard MD and Prof José Cunha-Vaz Prof José Cunha-Vaz MD congratulates Bill Aylward as he takes up his new role as EURETINA president

IN his Kreissig lecture at the 9th EURETINA Congress in Nice, France , renowned retinal specialist Harvey Allen Lincoff MD, Weill Cornell Medical Centre, New York , US, discussed his area of particular expertise, retinoschisis, and the current best practice in eyes where the condition leads to retinal detachment. Dr Lincoff noted that retinal detachments which affect vision are a fairly rare complication of retinoschisis, which is in general a fairly benign condition. When retinal detachments do occur in such patients they are most generally located in the inferior portion of the eye and unlike most other types of retinal detachment, do not progress. In eyes where no vision has been lost, the best treatment strategy is monitoring over the long term, he emphasised. Moreover, even when vision is affected, a less invasive approach will generally produce the best results, Dr Lincoff pointed out. In particular, vitreous-based treatments such as vitrectomy are not indicated, because the retinal detachment that results from retinoschisis has a completely different, infra-retinal pathophysiology, which does not involve the vitreous, he continued. The standard practice in adult retinoschisis patients with vision-affecting retinal detachments is the placement of a scleral buckle, he said. While this treatment works, simple binocular occlusion for a few days is also very effective in most patients and is a useful approach in patients in whom surgery is contraindicated. Dr Lincoff recalled a sentinel case he had 15 years ago, whose management first demonstrated the efficacy of binocular occlusion. The patient was a 12-year-old boy with a central retinal detachment whose parents balked at the prospect of their child undergoing surgery with anaesthesia. Since the case was not urgent, given the non-progressive nature of the detachment, Dr Lincoff sent the child home for a few days, hoping the parents would later consent to the surgery. However, when he examined the child on his return he saw that the detachment had resolved itself. “We found that the detachment that occurs from retinoschisis is a very benign affair and can be treated very effectively by binocular occlusion and then the retinal will flatten out in a day or two and you just have to laser the little holes that occur and it’s all over,” Dr Lincoff said. He added that binocular occlusion in home setting can be made more tolerable by adopting a practice he calls ambulatory binocular occlusion. It involves allowing patients to lift their eye covering slightly and peek underneath it when absolutely necessary, such as when walking up the stairs or going to the bathroom. “So long as you cover both eyes and arrest gaze movements we have found that the retina will flatten out. So what we’re saying is that while the primary operation is a scleral buckle, if you’ve got a child or the detachment threatens the macula there is a contraindication to surgery and you treat the patient with binocular occlusion,” he said. PATIENTS with intermediate AMD demonstrate a high compliance in unsupervised home usage of a home-based perimetry device for the early detection of choroidal neovascularisation (CNV), according to Anat Lowenstein MD. “Our experience shows that usage compliance of these intermediate AMD patients with the ForeseeHome device is adequate for the detection of CNV within a reasonable time frame,” she said. Dr Lowenstein explained that the device is based on Preferential Hyperacuity Perimetry (PHP) technology, and the efficacy of its detection algorithm depends on the frequency of usage, particularly in highly fluctuating patients performing the test. The 15 patients recruited to the study received a packed device with instructions to test either both eyes or only one eye if the other eye did not meet the inclusion criteria. The patients were told to use the device at their convenience, at home and as frequently as possible. No supervised assistance was offered except for a support hotline. Over the seven-month follow-up period, two types of patients were identified: “organised” patients, who used the device in a narrow range of hours, and “spontaneous” patients who used the device at arbitrary times. The frequency of usage was higher in organised patients compared to spontaneous patients. “Patients using the device at fixed times during the day have a better compliance and hence a shorter expected detection time,” she told the 9th EURETINA Congress in Nice, France. RETINAL detachment patients with proliferative vitreoretinopathy who undergo vitrectomy alone are at a higher risk of retinal detachment recurrence than are those who undergo vitrectomy combined with scleral buckling, according to the results of a study presented at the 9th EURETINA Congress by Ahmed Shoeir MD, Research Institute of Ophthalmology, Cairo, Egypt. “There is a controversy about scleral buckling with pars plana vitrectomy. The success rate of pars plana vitrectomy plus silicone oil injection and scleral buckling has reached up to 90 per cent which is very acceptable. But many studies suggest the same results can be achieved with vitrectomy and silicone oil alone,” Dr Shoeir said. The study involved 40 consecutive eyes with rhegmatogenous retinal detachment with PVR grade C which were offered either vitrectomy and silicon oil injection in combination with encircling scleral buckling procedure or vitrectomy and silicon oil injection alone. Main outcome measures were reattachment with a single surgery, visual acuity (VA), and detachment after silicon removal over the study period. HIGH-RESOLUTION imaging technologies are helping clinicians to shed light on the role of the vitreous in age-related macular degeneration (AMD), according to a study presented at the 9th EURETINA Congress in Nice, France. “The changes and pathologies of the vitreo-macular interface have been examined in several macular disorders including macular pucker, macular hole and diabetic macular oedema, while the exact role of the vitreous in age-related macular degeneration has not yet been sufficiently examined,” Dr Ilse Krebs said. Ultrasound and OCT examinations of 163 eyes detected posterior vitreous detachment (PVD) in 72 per cent of eyes with dry and 34 per cent with wet AMD and vitreo-macular adhesion in seven per cent of eyes with dry and 36 per cent with wet AMD. Dr Krebs concluded that there is a strong association between dry AMD and PVD and that as a result of anomalous PVD, vitreo-macular adhesion is associated with wet AMD. She added that the results seem to be independent of genetic and environmental factors. Looking to the future, she said that advanced imaging technologies would continue to give researchers more information on the precise location of the adhesions, traction directions and forces of the vitreous. AN electronic subretinal implant in investigational trials can enable blind retinitis pigmentosa patients to read letters from a screen and recognise the direction of fine stripe patterns, Eberhart Zrenner MD, University of Tuebingen, Germany told the 9th Congress of EURETINA. The subretinal implant consists of a 3.0mm by 3.0mm array of 1500 photodiodes which act as light sensors, a neighbouring array of electrodes which stimulate the bipolar cells, and an external energy source attached to the implant via a cord which passes from behind the ear into the eye. It also has an array of 16 electrodes which are directly stimulated by the energy source for testing and calibration purposes. The retinal chip is implanted transchoroidally near the macula. So far, 11 retinitis pigmentosa patients who have been blind for two to 15 years have undergone implantation with the chip. The surgery was free of any major complications such as retinal detachment and haemorrhages. Less is more for eyes with retinal detachment from retinoschisis New imaging technologies highlight role of vitreous in AMD Electronic subretinal implants may provide useful vision to blind retinitis pigmentosa patients Good patient compliance found with home-based CNV detection device Better outcomes with buckling and vitrectomy than with vitrectomy alone Our reporters in Nice were Dermot McGrath and Roibeard O’hEineachain. Harvey Allen Lincoff

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Feature T o glimpse the cable cars topping Nob Hill between bay windows and iron balconies you might think nothing had changed in the century since this city was one of America’s leading ports. But these days, there is little evidence of the port’s glory days. Now, most ships running the tides through the Golden Gate sail past the storied wharves of San Francisco to the faceless intermodal container facility across the bay in Oakland. There’s just no room in San Francisco for the vast rail and truck yards needed to efficiently serve modern container ships. High technology, finance, and tourism are now major industries, making San Francisco a cultural and business centre better known for its restaurants, boutiques and museums than its anchorage. Transformation of another sort was much on the minds and lips of ophthalmologists attending the 2009 annual meeting of the American Society of Cataract and Refractive Surgery (ASCRS) here. A perfect storm of a rapidly ageing population, few ophthalmologists in training, and budget woes for government insurance programmes are driving many ophthalmologists to reshape their practices with an eye toward improving efficiency and throughput – and income. While many issues addressed at ASCRS were specific to the US, they parallel developments in European countries facing similar demographic and economic pressures. Financial incentives to reshape practice One change prompted by new government rules is electronic medical records. Physicians can earn up to $44,000 in Medicare payment bonuses over five years starting in 2011, followed by penalties for not using them afterward. Many practices already use computerised records, and some believe they improve care and administrative efficiency. Still, in the exhibit halls and conference rooms, much grumbling was heard about the cost of computerised systems and their possible interference with physician-patient communication. Also on the government and insurance agenda is new payment methods designed to “incentivise” more effective and efficient care. “We are moving to a system based on quality, not quantity,” said Priscilla Arnold MD, chair of the ASCRS government relations committee. These new approaches include payment for following evidence- based treatment protocols and promoting the “medical home” concept, in which patient care, including ophthalmic care, is coordinated by a primary care physician. They’re also toying with payment changes such as “gain-sharing,” in which doctors and hospitals may keep any savings they generate through closer collaboration. Other tactics under consideration include bundling more tests and office visits into payments for surgical procedures, and combining hospital and physician payments into a single flat rate for an episode of care to reduce redundant services. A lot of research still needs to be done to keep such systems from penalising doctors who take on the most complex cases, noted William Rich III MD, medical director for healthcare policy for the American Academy of Ophthalmology (AAO). Flat- fee arrangements have generated similar disincentives to treat complicated patients in Germany and elsewhere in Europe. “There is no transparent, validated adjustment for the severity of disease or co-morbidities. There is no way to differentiate from claims data an episode provided by a glaucoma specialist from that of a general ophthalmologist or an optometrist,” Dr Rich said. Nonetheless, many private insurance companies in the US already use claims data to rank ophthalmologists and other physicians according to the costs they generate for patient care, Dr Rich said. “All glaucoma doctors are in the high-cost tier,” he noted. Other ophthalmic specialists and academicians also find themselves classified as “high cost,” which often means that if patients want to see them, they must get special permission from their insurance companies or pay higher out-of-pocket fees. In some private plans, services from these “high cost” doctors may not be covered at all. Several states are reviewing the legality of these arrangements, but they are becoming more common as a way to control costs. Several specialty groups, led by the American College of Surgeons, are cooperating to develop better data collection systems and measures to anlayse surgical outcomes, Dr Arnold added. Greater role for non-physician providers Some ophthalmologists are changing their practices even more fundamentally by expanding the role of optometrists and other non-physician specialists. A few have gone so far as to turn over routine medical screening and even medical management of stable glaucoma and surgical follow-up almost entirely to optometrists and nurses, leaving themselves more time to operate and see the most complex cases. Several considerations are driving this change, including a need for improved efficiency, higher patient throughput and a more effective use of scarce patient care assets, said Stephen Lane MD, Minneapolis, US. The three ophthalmologists in Louis D Nichamin MD’s practice in rural Pennsylvania work closely with eight optometrists, he said. “The whole idea is to make our schedule as efficient as we can, and allow us to do what we want to do, which is surgery. We only want to see surgical consults and complicated or high- grade pathology that goes beyond the scope of an [optometrist’s] training, and patients who insist on seeing an ophthalmologist.” Developing optometrists’ skills to the point where they can be relied on for such complex tasks can take time. They must also be supervised to ensure ongoing quality of care. But it’s worth it, Dr Nichamin said. “They are more than assistants; they are truly colleagues.” The growth of such integrated practices marks a departure from the widespread antipathy toward optometrists, whom many ophthalmologists see as interlopers trying to cut in on their turf, Dr Lane said. These conflicts have been fanned in recent years by attempts in several states to allow optometrists to perform surgery, for which they are not trained. One result has been the banning of optometrists from attending some ophthalmology meetings, notably the AAO. But not ASCRS, where several optometrists presented in a symposium on integrated practice models. “There is controversy and angst between ophthalmologists and optometrists, but people who have participated in these arrangements find them productive,” Dr Lane said. “It may be that the best way to control what optometrists do is to have them in your own practice.” This is change indeed. 38 Letter from America Tides of change for ophthalmology Government budget shortfalls and looming demand tsunami may push new practice models by Howard Larkin Oculus Optikgeräte GmbH • 35549 Wetzlar • GERMANY Tel. +49-641-2005-0 • Fax +49-641-2005-295 www.oculus.de The Centerfi eld is a compact visual fi eld analyser, based on well-accepted Goldmann standards. It offers a wide variety of areas up to 70 degrees and strategies, including kinetic and blue/yellow perimetry. Confi guration depending on country Centerfi eld2 The Oculus Centerfi eld2 Real Compact CLIP – (Continuous light increment pe rim e try) The unique real threshold test that outperforms most interpolation based algorithms. Includes 'WTQVKOGU%GPVGTHKGNF$NCEMZ

39 Regulatory Updates FDA warning to advertisers THE US Food and Drug Administration (FDA) issued a strong warning to US marketers of laser vision correction to clean up their promotional practices. The FDA, currently in the middle of an investigation of potential LASIK risks, wants anyone advertising LASIK services to include sufficient information on possible risks associated with the procedure. “Advertising and promotional materials for FDA-approved lasers used during LASIK procedures must be truthful, properly substantiated and not misleading,” wrote Timothy Ulatowski, head of the Office of Compliance for the FDA’s Centre for Devices and Radiological Health, in an advisory letter. Special designation for Akreos AO Bausch & Lomb gained the New Technology Intraocular Lens (NTIOL) designation for its Akreos Advanced Optics Aspheric IOL from the US Centres for Medicare and Medicaid Services (CMS). The enhanced designation means the Medicare reimbursement to ambulatory surgery centres for cataract surgery will increase by $50 when surgery is performed with the Akreos AO IOL. www.bausch.com AMD drug on the fast track Sirion Therapeutics gained US Food and Drug Administration (FDA) fast-track status for fenretinide, an experimental treatment for geographic atrophy associated with age-related macular degeneration. The fast-track designation provides Sirion with the option of submitting a new drug application (NDA) on a rolling basis, enabling the FDA to begin reviewing sections of the application before receiving the complete application. NDAs for products with a fast-track designation also generally receive a priority review designation, meaning the application will be reviewed in six months rather than the 10-month standard review time, the company notes. A phase III clinical study is planned. www.siriontherapeutics.com Staar gets FDA nod Staar Surgical gained a New Technology Intraocular Lens (NTIOL) designation from the US Food and Drug Administration (FDA) for its newest IOL, the Afinity Collamer Aspheric Single Piece New Technology IOL. The recently released IOL can be delivered into the eye using a proprietary injector system (nanoPOINT, Staar) through a 2.2mm incision, which the company maintains is the smallest incision used with any NTIOL on the market. The lens itself is composed of collagen, an ultraviolet-absorbing chromophore, and a poly-HEMA based co-polymer. Staar Surgical also has announced $100 reduction in the list price of its toric IOLs. www.staar.com Company news Distinction for Rayner Rayner, the only British company manufacturing intraocular lenses, has been awarded the prestigious Queen’s Award for Enterprise. The award recognises sustained international trade in overseas markets and growing commercial success. Rayner employs over 120 people, and trades in 67 markets worldwide. The company frequently donates IOLs free of charge to charities in developing countries. Rayner was founded in 1910 by optician J B Reiner (Rayner). In the 1940s, British surgeon Sir Harold Ridley worked closely with Rayner on the world’s first IOL. www.rayner.com NuLens recognised NuLens Ltd, an Israelis company developing an innovative accommodative IOL, was named a WINNER of the Red Herring 100 Europe, an award given to the top 100 private technology companies based in the EMEA region each year. Red Herring is a global media company that unites the world’s best high technology innovators, venture investors and business decision makers in a variety of forums. www.nu-lens.com www.redherring.com Smooth sailing for Alcon The Alcon Foundation announced a $50,000 grant to Mercy Ships that will fund two, three-month fellowships in advanced cataract techniques for expatriate or national West African surgeons onboard the Africa Mercy, a hospital ship in Cotonou, Benin, West Africa. The fellowships are designed to complement additional training done with community eye workers and local eye surgeons to help build capacity during the ship’s 10-month port visit. Alcon has partnered with Mercy Ships since the charity’s inception 30 years ago. Since 1997, the company has donated more than $5.6m worth of equipment, supplies, and pharmaceuticals to support the organisation’s efforts to address preventable blindness. www.alcon.com/en/corporate-responsibility/ alcon-foundation.asp Clinical trials Retinal implant advances The US Food and Drug Administration (FDA) gave approval for Second Sight Medical Products to expand its clinical studies of a new retinal implant. The approval gives the green light to implant the device in up to 20 people with retinitis pigmentosa who are either blind or severely impaired visually. The Second Sight system includes a 60-electrode grid that is implanted surgically and attached to the retina. The electrodes transmit information from an external video camera that is mounted on a pair of eyeglasses. Studies with another 22 patients are currently under way in Mexico and Europe. The European participants include Central Manchester University Hospital in Manchester, England; Le Centre Hospitalier National d’Ophtalmologie des Quinze-Vingts, Paris; Moorfields Eye Hospital, London; and Service d’Ophtalmologie, Hôpital Cantonal Universitaire de Genève, Geneva, Switzerland. www.2-sight.com/ New Products The best of both worlds Geuder AG launched a new “hybrid” instrument series for anterior segment surgery (see above). Developed in cooperation with Prof Lars-Olof Hattenbach, MD, of the Ludwigshafen Eye Clinic, the new series combines the 25-gauge format used in vitreoretinal surgery with an angled handle common to anterior segment surgery. One such instrument, a pair of capsulorhexis forceps, offers maximum anterior chamber stability and flexible access through either incision or paracentesis. The shape was optimised to enable a secure grasp and control of the capsule. Additional instruments in this 25-gauge hybrid series include scissors and tying forceps. www.geuder.de B&L instruments Bausch & Lomb introduced a new website dedicated to the surgical instruments business. The company says visitors to www.storzeye.com will experience improved navigation and updated content, providing a quick and convenient channel for fulfilling their ophthalmic instrument needs. www.storzeye.com OcuSeal in Europe Ophthalmic Systems, a unit of BD (Becton, Dickinson and Company), announced the European launch of BD OcuSeal Liquid Ocular Bandage. The innovative polymer liquid bandage was designed to provide an alternative to conventional sutures and cyanoacrylate adhesives for closing corneal incisions and wounds. This product has European CE Mark approval, and BD intends to initiate registration in other countries including the US. www.bd.com Industry News Industry News Recent developments in the vision care industry

Instant Clinical Diagnosis in Ophthalmology – Glaucoma Editors: Shlomo Melamed, Tanuj Dada, and Ahmad K Khalil. Foreword by Robert N Weinreb Series Editors: Ashok Garg and Emanuel Rosen T he introductory material to medical textbooks and handbooks generally adopts a somewhat optimistic, even triumphalistic, tone about what has been learned and what the future will bring. Dr Robert N Weinreb strikes an unusually pessimistic note in his foreword to this handbook. He writes that, “at times, it has seemed that what has been learned through basic research has been inadequate to justify its time and effort. Also the pace of translational clinical research often has appeared to be so slow, and certainly not fast enough to have a major impact on glaucoma blindness.” For Weinreb, many basic issues need to be addressed, particularly the last of a clear, consistent definition of glaucoma. Nevertheless, he believes we are on the verge of a paradigm change in diagnosis and treatment that will revolutionise the prognosis of glaucoma. A tension between the incremental and somewhat serendipitous progress of basic science and the demands of clinical need is well recognised. Policymakers and the general public, as well as clinicians, often require that research take a certain direction, and the whole basis of funding for research in the modern world tends to be goal- directed rather than being aimed at knowledge for its own sake. Unfortunately, basic science is rarely so co-operative in responding directly to goals or even huge sums of money. The temptation is often to decide that we know enough basic science to move on and use existing knowledge to improve therapy. The classic example was the so-called “War on Cancer” launched by US President Richard M Nixon in 1971. After the euphoria of sending a man to the moon, Americans felt that a similarly concerted application of known science to cancer would surely lead to a cure. Basic science was downgraded in favour of purely therapeutic research. Later, some of the architects of the War on Cancer would admit that it was the basic science research into oncogenetics that really revolutionised cancer care, and really holds out the promise of future therapeutic innovation, but this research was downgraded. For Weinreb, there is now a conjunction of new and improved tools to assess glaucoma, improve diagnostic and therapeutic tools, and new clinical approaches, which together will hopefully deliver this promise. Synthesising all this knowledge and evidence, and trying to apply it to the clinical setting, is a challenge. This book is an attempt to perform that task. It is divided into two broad sections: Clinical Glaucoma and Special Glaucoma Surgical Techniques. The first section begins with early onset develop-mental glaucoma and proceeds through the presentations of the condition in adults and in children. From the beginning, the focus is clinical and, unlike other books previously reviewed in this column, the authors assume that the reader knows basic optics and ocular anatomy and physiology. The book is richly illustrated with colour plates and photos, as well as with diagrams. The later sections of the book, in particular, combine personal experience with descriptions of the evidence base for interventions. This is because innovative surgical approaches are being dealt with, and an evidence base is being developed. This approach also allows contributors to make the reader aware of regional variation in management and treatment. For instance, Jes Mortensen of Sweden, in describing visco-canalostomy procedures, mentions the fact that in dissecting a flap to Descement’s membrane through Schlemm’s canal, one needs to take great care to find the marker in “the modestly pigmented eyes of Swedish patients.” Touches like this, justify the multi-author format which reflects a truly international cast of contributors, ranging from India, Egypt, Russia, South Africa, the Netherlands, Sweden, Italy, Portugal, Germany, Israel, the UK, Mexico, France, Spain, and Switzerland. Other books in this series on instant clinical diagnosis in ophthalmology have been reviewed here, and I have previously made the point that while they are impressively produced volumes, they are not vade-mecums along the lines of the Oxford Handbooks. These kind of books demand a great deal of user friendliness, and the book should be laid out so the relevant information for a clinical presentation can be found as quickly as possible. I would have liked to have seen a greater use of summary boxes and tables throughout the text, and perhaps more use of flowcharts outlining procedures and investigations. Some of the information is located within the text, whereas ideally in a book of this kind the text should be a reference for the outline of practice. This volume seems slightly less reader friendly than others in this series. A flowchart leading from presenting symptom to both diagnosis and therapeutic approach would have been useful. At times the multi-author format lends itself to a lack of unity of structure and design. As outlined above, this volume demands a certain level of pre-existing expertise which clearly reflects the target readership of practising ophthalmic surgeons, ophthalmologists, and ophthalmic doctors in training. Introductory material is available from other sources. Feature 40 In Your Good Books On the verge of a paradigm shift in glaucoma careby Seamus Sweeney            ‹$QJLRWHFK3KDUPDFHXWLFDOV,QF ‹6XUJLFDO6SHFLDOWLHV&RUSRUDWLRQ $OOULJKWVUHVHUYHG23*30 $QJLRWHFK'HQQLV'ULYH5HDGLQJ3$       \ [ The IQ Geometry™ Knife’s innovative design performs beyond standard knives: Hollowed bevel design minimizes tissue contact, resulting in a 37% reduction in penetration force* 40+% thinner than standard blades results in a superior wound architecture* Sharpoint™ Infinite Edge™ proprietary finishing technology for consistent sharpness *Data on file. 999T*#421+06T%1/ 106#%675 (14#241&7%6'8#.7#6+10#6 *#421+06u#0)+1T%1/ 14KGFJFJgJHJJ $1*B,4JHRB(XUR7LPHVB-XO$XJLQGG30

41 Normal tilt, normal correction Modern IOL design and surgical technique allow surgeons to minimise, but not eliminate, IOL tilt and decentration. How do aspheric IOLs compare with conventional spherical IOLs in this regard? Researchers compared tilt and decentration of a conventional spherical IOL and a prolate surface-modified IOL with negative spherical aberration in an intra-individual setting. Twenty-one patients received a spherical IOL (Sensar AR40e, AMO) in one eye and of an aspheric IOL with negative spherical aberration (Tecnis Z9000, AMO) in the contralateral eye. At three to four months postoperatively, IOL tilt or decentration were minimal, with no significant differences based on lens type. Wavefront measurements also showed no significant differences in mean residual higher order aberrations. The researchers conclude that when IOL tilt and decentration are within normal limits, they do not compromise the correction of spherical aberration by the aspheric IOL. M Baumeister, JCRS, “Tilt and decentration of spherical and aspheric intraocular lenses: Effect on higher-order aberrations”, Volume 35, Issue 6, pages 1006-1012. Variations in pachymetry with OCT, US, Scheimpflug Clinicians have an increasing array of options for measuring corneal thickness, but how do these compare? Investigators at the Cole Eye Institute compared central and peripheral corneal thickness using Scheimpflug imaging (Pentacam, Oculus), high-speed optical coherence tomography (Visante OCT, CZM), and ultrasound pachymetry (Sonogage Corneo-Gage Plus) in normal, keratoconus-suspect, and post-laser in situ keratomileusis eyes. The analysis of 163 showed that ultrasound pachymetry central corneal thickness measurements were consistently higher than Scheimpflug and OCT measurements (mean difference 6.5 μm ± 1.8 [SD] and 7.5 ± 1.4 μm, respectively) in normal eyes, a statistically significant difference. The difference was similar and not greater with keratoconus suspicion, age, or absolute magnitude of corneal thickness. Scheimpflug measurements were significantly lower than ultrasound pachymetry in post-LASIK eyes. There was no statistically significant difference (mean 0.9 ± 1.4 μm) in Scheimpflug and OCT central corneal thickness measurements, although Scheimpflug measurements were significantly lower in post- LASIK eyes. Scheimpflug peripheral corneal thickness measurements were higher than OCT measurements, showing more agreement with increasing age. C Ponce, JCRS, “Central and peripheral corneal thickness measured with optical coherence tomography, Scheimpflug imaging, and ultrasound pachymetry in normal, keratoconus- suspect, and post-laser in situ keratomileusis eyes”, Volume 35, Issue 6, pages 1055- 1062. LASIK after multifocal IOLs? LASIK following multifocal IOL implantation poses a number of challenges. A new study looked at the visual and refractive outcomes of LASIK performed to correct residual refractive error after apodised diffractive multifocal IOL implantation. The study reviewed 85 eyes of 59 consecutive patients who had LASIK using the IntraLase FS60 femtosecond laser and Visx Star S4 excimer laser (AMO) to correct residual refractive error after AcrySof ReSTOR IOL (Alcon) implantation. Thirty-six eyes (42.3 per cent) had myopic correction, 35 (41.2 per cent) had mixed astigmatic correction, and 14 (16.5 per cent) had hyperopic correction; 45 eyes (52.9 per cent) also had Nd:YAG capsulotomy. Six months after LASIK, 91.8 per cent of eyes had an uncorrected distance visual acuity of 20/25 or better, 92.9 per cent had an uncorrected near visual acuity of J1 or better, and 85.9 per cent had 20/25 or better UCVA concurrent with J1 or better UCNVA. No eye lost more than one line of best spectacle-corrected visual acuity; two eyes lost one line. Ninety-nine per cent of eyes were within 1.00 dioptre of emmetropia, and 98 per cent of eyes were within 1.00 D cylinder. There was no significant difference in postoperative UCVA or UCNVA between the three refraction groups or between eyes that had Nd:YAG capsulotomy and those that did not. The researchers conclude that this approach is predictable, effective, and safe. O Muftuoglu, JCRS, “Laser in situ keratomileusis for residual refractive errors after apodized diffractive multifocal intraocular lens implantation”, Volume 35, Issue 6, pages 1063-1071. JCRS Highlightsby Thomas Kohnen Journal of Cataract and Refractive Surgery jointly published by the ESCRS and ASCRSJCRS Highlights Controversies in Cataract and Refractive Surgery 2009 Sunday, September 13, 2009, 14:30–16:30 Chairs: Emanuel S. Rosen, FRCSE, Thomas Kohnen, MD n Which Diagnostic Is the Most Important for Keratectasia-Ectasia Risk Factors? Placido Topography Versus Scheimpflug Imaging n Excimer Laser for Hyperopia: What Are Age and Degree Limits? Modest Limits Versus Wider Limits n Blue Light–Filtering IOLs Pro’s and Con’s n Simultaneous Bilateral Cataract Surgery Pro’s and Con’s During the XXVII Congress of the ESCRS, Barcelona, Spain

Feature W ith a major share of the world spectral domain OCT market and an automated non-mydriatic retinal camera leading the way, Topcon is tops in ophthalmic diagnostics. Now, the Tokyo-based firm’s European subsidiary has added intraocular lenses and ocular surgical products to a lineup already featuring top-shelf diagnostic systems for both cataract and retinal applications, surgical microscopes, slit lamps and refractive equipment. “We are now offering a more complete solution to our end users,” says Mark Lansu, marketing and sales director of the surgical business unit for Topcon Europe Medical, of Rotterdam, The Netherlands. With the firm already providing surgeons with equipment for preoperative, operative and postoperative care, adding surgical consumables makes the firm more of a one-stop shop. “Combining diagnostics and surgical creates a lot of synergies for the operating surgeon.” Topcon launched its surgical business unit in September at the XXVI Congress of the ESCRS with the announcement of a partnership with Oculentis, of Berlin, Germany. Topcon’s network of European subsidiaries now offer Oculentis intraocular lenses, viscoelastics and retinal fluids alongside its own surgical microscopes and diagnostics equipment. Adding surgical disposables not only creates convenience for surgeons, it allows Topcon to build a closer relationship with its customers and better serve their needs, Mr Lansu says. The goal is not just to offer new products, but new solutions that integrate preoperative and postoperative diagnostics with operative products to improve surgical care and outcomes. Oculentis was a good fit for this service-oriented model because it has traditionally emphasised working directly with surgeons not only to make sure they get precisely the products they need in the right quantity at the right time, but also to develop new lenses and fluids as new needs arise. In addition to a full range of intraocular lenses and viscoelastics, also vitreoretinal products are available including high purity silicone oils in different viscosities for use as long-term retinal tamponade and 100 per cent fluorinated perfluorocarbon as short-term tamponade. Over the next three years or so, Topcon is looking to broaden its surgical offerings, Mr Lansu adds. Topcon Europe Medical is taking the lead to develop its surgical business unit because its European subsidiaries have been innovative in moving outside the diagnostics arena, Mr Lansu says. Some of Topcon’s European subsidiaries already handled some surgical products before the new unit was formed. The new business unit streamlines and coordinates these relationships so the entire network now supports surgical products. If all goes well, the concept could be expanded to other parts of the world. “I think we are something like a guinea pig.” In the first six months, the venture is growing despite its launch at the beginning of the most severe economic downturn in half a century, Mr Lansu says. In part, that’s because cataract surgery is less affected by recession than some other segments of the ophthalmic industry. But growth hasn’t been as strong as he’d like. “It’s taking longer than I would have expected at the beginning.” In diagnostics, sales of the state-of- the-art 3D OCT-1000 Mark II device have also been strong. New FastMap 3D measurement software allows practitioners to visualise the layers of the retina, in addition to featuring a new diagnostic module for the anterior segment. Likewise, sales of Topcon’s TRC-NW8 non-mydriatic retinal camera also enhance retinal care. This camera features autofocus and exposure, along with built-in peripheral and standard fixation points, making it possible for operators with limited training to produce highly reproducible field studies. Ease of use and consistent results make the device ideal for telemedicine and retina screening programmes. These successes along with the new surgical business have helped Topcon to maintain its dominant position in Europe in the firm’s fiscal year 2008, which ended March 31, 2009. Eye care represents about 38 per cent of sales at Topcon, with about one-third each in Europe, Asia, and the US. The other major business activities of the firm are global positioning and surveying equipment, and quality control sensors for manufacturing microchips and other electronic devices. Eye Route software aims to improve practice efficiency This Web-based software package helps ophthalmologists improve practice efficiency by bringing all study images from all kinds of devices to any browser-enabled computer or even a smartphone. “I can take a picture of a retina with a non- mydriatic camera, and then view it over eyeRoute on my iPhone,” says Lon Dowell, director of image products marketing for Topcon Medical Systems, the firm’s US subsidiary. Mr Dowell notes that eyeRoute software saves time by eliminating the need to gather paper records and printouts from various imaging instruments made by different companies. With eyeRoute, when a surgeon wants to evaluate a patient’s tests, he or she logs on to a secured server and selects the patient’s name. All images can then be viewed. Immediate access to images from multiple modalities allows surgeons and other specialists to perform complex analyses in their heads. “The idea is that specialists don’t need a lot of sophisticated software tools; they need to see the images,” Mr Dowell says. It also saves time and increases patient flow. To date, the system can seamlessly integrate with more than 120 different instruments, Mr Dowell says. The software is installed on these devices, and as they generate images, they are catalogued and become available over the network. More devices are being added constantly. The system can be installed on a clinic or hospital server or can be remotely hosted by Topcon, eliminating the need for investments in new hardware and software for smaller practices. It is fully compatible with electronic medical record systems. Also, eyeRoute is fully scalable and customisable to meet the specific needs of practices large and small, Mr Dowell adds. In the US, eyeRoute already serves about 3,000 users and is installed at some of the largest eye clinics in the country. A pilot programme is planned in the UK. Topcon continues to demonstrate with these innovative solutions that it is in tune with today’s and tomorrow’s needs of the ophthalmic professional. mal@topcon.eu 42 Outlook on Industry Topcon adds ophthalmic surgery products in Europe Goal is to improve service, build stronger relationships with surgeons by Howard Larkin New Multifocal lens - the LENTIS Mplus Anterior segment of the eye made with the 3D OCT 1000 Mark II

Available to view now at www.conference2web.com/escrs n Symposia n Free Papers n Other Key Sessions Missed the XXVI ESCRS Congress in Berlin or the 13th ESCRS Winter Meeting? n Video Competition Winners n ePosters n Medal Lectures

Feature B y 1995, Jorge L Alió MD, PhD, had already attained broader influence than most in ophthalmology. As professor and chairman of ophthalmology at Alicante University in Spain, his clinical and research activities were internationally known, and his teaching was shaping a generation of ophthalmologists. Yet Dr Alió’s vision for his practice and for ophthalmology was even broader. He constantly saw opportunities to improve patient care and expand services with new procedures, technologies, research partnerships and innovative staffing. “We wanted to create new devices and treatments for our patients; to bring innovations directly into practice,” Dr Alió remembers. But making such changes at a public university was cumbersome. Partnerships with device manufacturers and other outside partners were difficult to negotiate and it could take years to secure funding for new programmes. “The academic structure is too rigid,” he notes. “You have to convince everyone to go along and it takes too long, so you lose the opportunity. There is no way you can make decisions quickly and independently within the university.” So Dr Alió set out to build a completely new, private practice model that would give him the flexibility to innovate. The result was VISSUM Instituto Oftalmológico de Alicante, a practice that has revolutionised not only the clinical practice of ophthalmology in Spain, but its financing and organisation as well. Dr Alió, who is also VISSUM medical director, and others will present on how they developed their practices at the second annual Practice Development programme at the XXVII Congress of the ESCRS, in Barcelona. A shared vision The biggest challenge in putting VISSUM together was assembling a team with a common vision, Dr Alió said. He is always looking for doctors inside and outside Spain to join the team. “It is more than a business project, it is a shared vision of practice that combines medical assistance and research, and making it work together with support from a financial structure. Some team members come by themselves, some you change and others you look for. Every person has a different approach, but they all have the same vision.” VISSUM integrates clinical services in all ophthalmic subspecialties, medical research, university teaching activities and humanitarian services under one umbrella organisation. Services are delivered by an integrated team including ophthalmologists, optometrists, medical technicians and researchers. All are trained to work together render personal service and the highest quality of evidence-driven care. “This is a co-management model that did not exist before in Spain,” Dr Alió says. VISSUM also supports the Fundacion Jorge Alió for the prevention of blindness, which provides services for those in need in Spain and abroad. “As doctors we need to devote time to humanitarian services,” he adds. VISSUM is supported by business operations, including billing for private insurance and self-pay, and financing for developing new procedures and devices. The structure allows practice leaders to quickly fund new services and open new locations as needed. It also provides flexibility to form research and business partnerships with outside companies that would be difficult for a public institution, Dr Alió explains. The concept of integrating research and business management to provide better clinical quality and improved service has been highly successful. VISSUM now operates 43 clinics across Spain run by more than 500 employees including about 60 ophthalmologists. Nine clinics include refractive laser and operating rooms to which patients are referred for surgery. Preoperative care and postoperative care are mostly done in local clinics, closer to patients’ homes. Dr Alió notes that excellent service is essential to success with private paying patients. About 30 per cent of the clinic’s business is refractive, another 50 per cent is cataract, including premium IOLs, and the rest other ophthalmic specialties, including glaucoma, ocular surface and vitreo-retinal. The practice serves about 200,000 patients annually and is growing despite the severe economic downturn. Dr Alió and his VISSUM colleagues have also conducted research on dozens of new procedures, devices and device applications including multifocal lenses and microincision cataract surgery. The hundreds of papers, books and presentations they have published have advanced and shaped the field of ophthalmology and benefited patients far beyond their own practice – just as Dr Alió envisioned. Launching a career and a practice While in training at the University of Ulm, in Germany, Eckhard Weingäertner MD also had a vision for a different type of practice. “I was exposed to refractive surgery, and it gave me ideas for different career options.” After completing his training, he was recruited by EuroEyes to open a new clinic in Stuttgart in 2003. Even though it meant building a practice from the ground up, Dr Weingäertner was ready for the challenge and became medical director. At the time, laser refractive surgery was fairly new and there were only a couple of practices offering LASIK in Stuttgart, says Dr Weingäertner, who will also present at the ESCRS congress. With a lot of high-end executives from companies including Porsche and Daimler in the area, the market looked ripe for a high-end refractive operation. He stressed the importance of identifying a strong potential market before investing in a new refractive practice. With no word-of-mouth referral base in place, EuroEyes promoted the practice through newspaper ads, press conferences and a strong web presence. Information nights and free evaluations of cornea thickness helped bring in patients. For a small fee, patients receive a full evaluation from a surgeon. Just as important was internal marketing. EuroEyes and Dr Weingäertner spent countless hours recruiting friendly staff, and then rigorously training them in customer service and how to talk to patients and make them comfortable. “Everything has to work together – the staff, the website, everything you say to the patient,” he says. It took two years for the location to break even, but it has been profitable ever since, even since the economic downturn, Dr Weingäertner said. Now about 20 per cent to 30 per cent of patients are word-of-mouth referrals. The practice spends about 15 per cent to 20 per cent of its total budget on marketing. One highly visible tactic is to wrap city buses in EuroEyes advertisements. “It’s expensive, but it gets you noticed,” Dr Weingäertner says. He suggested that surgeons looking to enter or stay in refractive practice in the current down market also offer lenses and cataract procedures in addition to laser surgery. While advertising, marketing, and the use of non-surgeon caregivers contribute significantly to the success of many practices, laws and ethical standards regulating their use vary considerably from country to country, according to Paul McGinn BL, a barrister who specialises in medical liability in Ireland. “It’s probably a good idea to go over your marketing and advertising materials as well as your plans for using non- ophthalmologists with a lawyer in your own country,” he advises. “Also, it’s a good idea to liaise with your medical society and physician registration body to ensure that you comply with national and local requirements.” jlalio@vissum.com Weingaertner@euroeyes.de paulrmcginn@eircom.net 44 “It is more than a business project, it is a shared vision of practice that combines medical assistance and research, and making it work together with support from a financial structure. Some team members come by themselves, some you change and others you look for. Every person has a different approach, but they all have the same vision” Jorge L Alio MD, PhD “It’s probably a good idea to go over your marketing and advertising materials as well as your plans for using non- ophthalmologists with a lawyer in your own country” Paul McGinn BL Practice Development My Life, my Practice Ophthalmologists to share experiences building practices at ESCRS Congress in Barcelona by Howard Larkin

Journal Watch Diabetes affects corneal hysteresis Patients with Type I diabetes appear to have lower degrees of corneal hysteresis, a finding that could have clinically relevant implications in measurement of intraocular pressure. Researchers used the Ocular Response Analyzer, ultrasound pachymetry, and Goldmann applanation tonometry to compare corneal biomechanics in diabetics and healthy controls. Corneal hysteresis was statistically significantly lower in the diabetics. Mean central corneal thickness and IOP were both significantly higher in diabetics. A Sahin et al., Invest Ophthalmol Vis Sci, “Corneal biomechanical changes in diabetes mellitus and their influence on intraocular pressure measurements”, 2009; May 14, doi:10.1167/iovs.08-2763. Monkey see, monkey do Researchers reported findings that synchronised coupling occurs in the high- energy gamma frequency range between two separate regions of the brain in monkey studies. This discovery suggests that this kind of electrical coupling is a general mechanism for regulating interactions across brain structures. The researchers took paired electrical recordings of both the frontal eye field (FEF) and the V4 area of the cortex and observed that when the monkeys paid attention to a visual stimulus in the joint receptive field, shared by both the FEF and V4, neural activity in the V4 area became synchronised with the activity from the FEF. This contradicts the previous dogma that this synchronicity in the gamma frequency range could not survive long- range connectivity in the brain. G Gregoriou et al., Science, “High-Frequency, Long-Range Coupling Between Prefrontal and Visual Cortex During Attention,” 29 May 2009, Vol. 324, 1207. The shape of things to come? Could therapeutic contact lenses help slow the apparent epidemic of myopia? A recent study suggests this may be possible. Researchers fit 40 paediatric patients with myopia ranging from -0.75D and -4.00D myopia and less than 1.00D of astigmatism with contact lenses designed to reshape their corneas. Previous anecdotal reports suggest that such an approach might slow eye growth. Age-matched children wearing soft contact lenses served as controls. After two years, the corneal reshaping group had an annual rate of change in axial lengths significantly less than the soft contact lens wearers. JJ Walline et al, British Journal of Ophthalmology, 4 May 2009, doi:10.1136/ bjo.2008.151365. AMD and diet A new study serves up another helping of evidence supporting the role of diet in reducing the risk for age-related macular degeneration (AMD). Researchers in the Age-Related Eye Disease Study (AREDS) group developed a composite scoring system to summarise the combined effect of multiple dietary nutrients on AMD risk. Application of the system revealed that higher compound scores were associated with lower risk for early AMD, indicated by drusen, and advanced AMD. Those results were statistically significant. The researchers conclude that older adults who eat diets rich in citrus fruits, leafy greens and fish oil, but low in glycaemic index, may have a lower risk of age-related macular degeneration. Chung-Jung Chiu et al, Ophthalmology, “Dietary Compound Score and Risk of Age-Related Macular Degeneration in the Age-Related Eye Disease Study”, May 2009, Vol. 116, No. 5, 939-946. 45 by Sean Henahan Vision science highlights from the world’s leading journals of medicine and scienceJournal Watch www.oertli-instruments.com Ecknauer+Schoch ASW Unparalleled Performance Oertli OS3/NovitreX3000®– the combi system for premium performance in phaco and vitreoretinal surgery. • Superior functionality • Sophisticated design • Sets the standard in micro- incision surgery Oertli OS3/NovitreX3000®– an investment that pays for itself immediately. www.oertli-os3.com Ins_OS3_250x140e_EuroTimes

Feature W e’ve all heard the horror stories about consent. We all know of a colleague who forgets to disclose the theoretical risk of a bad outcome before a procedure and the unsettling discovery when that bad outcome materialises after surgery. As a lawyer, I always stress that ophthalmic surgeons should disclose to their patients any risks that they believe can help the patient make a decision about whether to go ahead with surgery. That doesn’t mean that a surgeon has to disclose absolutely all risks. But it does mean that you have to disclose risks that reflect the needs and understanding of the patient, the limits of the procedure, and perhaps most importantly, your own clinical abilities. Full disclosure means taking time to explain to a patient, not only in a general way, about a procedure and its risks but specifically about how the procedure you propose for this particular patient will affect that patient. Ophthalmologists often say they don’t have the time to be so careful. I say you have to make the time. In case after case, patients who sue or complain claim that their surgeon didn’t give them enough information about the operation or didn’t give enough time to decide whether the operation was right for them. To illustrate that point, consider the case of a 27-year-old musician who developed diplopia after strabismus surgery in an eye hospital in Dublin in 1994. That case has become one of the leading cases in Ireland about consent and medical treatment. The patient attended the hospital in November of 1993. There, an orthoptist tested and evaluated his vision. The orthoptist then referred the patient to an ophthalmic surgeon, who the patient met in December of 1993 and again in February of 1994. After that review, the surgeon decided the patient was suitable for surgery. The plaintiff then received a letter informing him of his operation on March 10, 1994. When he showed up for his surgery that day, the patient learned that a trainee surgeon – and not the surgeon who saw him before – would operate. The trainee, who had already performed a number of squint operations, referred to the notes of earlier examinations and also the report of the orthoptist who had first seen the patient. In that report, the orthoptist had raised various points for the surgeon’s consideration, including not only the possibility of surgery for the squint in the left eye, but also the possibility of a single right medial rectus recession in the good eye. The plaintiff met the trainee surgeon about 30 minutes before he was due to undergo surgery. At that stage, the plaintiff was in a gown and in a bed in a ward of the hospital. He does not appear to have been sedated as part of his premed for the operation. According to the patient, the trainee doctor spent about 10 minutes with him; he had a clipboard and was taking some notes. According to the patient, the trainee surgeon said there was a good chance that the eye would be straight following the operation, but “it won’t be 100 per cent straight. There is a good chance there will be a good cosmetic improvement. The only thing is that when you go into your 40s the muscles might start to drop back a little bit and you might want to get it corrected again.” The patient also claimed that during the course of the 10-minute conversation, the trainee surgeon did not mention any complications, side- effects or adverse consequences that might ensue. The patient did admit that he signed a standard consent form to undergo the operation. However, the consent form did not specify any risks associated with the proposed procedure. The patient also claimed that had he been told about the risk of muscle loss or slippage resulting in double vision, he would have “walked straight out of the hospital”. For his part, the trainee surgeon said he could not specifically recall meeting the plaintiff on the date in question or the operation itself. Instead, he had to refer to his notes, which indicated that he had checked the patient’s vital signs and had reviewed the orthoptic report and other previous records in the patient’s medical notes. There was no record of any discussion about the risks of the squint surgery. In light of the absence of such a record, the trainee surgeon said that it was his practice to explain to patients how he would perform the surgery, including the use of adjustable sutures and that the patient would have to attend on the day after surgery to correct the alignment. The surgeon also said that it was his practice to identify common complications that could arise, including under-correction, over-correction, and diplopia. He also said that it was his practice to warn about such further complications as the loss or slippage of a muscle and also about the perforation of the eye during the procedure. In his defence, the trainee surgeon contended that taking consent so close to the time of the operation without any prior discussion about the procedure was the norm at that time for day case patients. The patient underwent the operation and was discharged home. On the next day, the patient returned to the hospital, where the same trainee surgeon adjusted the suture to maximise alignment. In the months that followed, the patient’s left medial rectus muscle gradually slipped. Three years after the operation, the patient sued for medical negligence. His allegation did not centre on the operation itself – which the patient said was performed correctly. Rather, the patient alleged that he would never have undergone the operation if he had been properly informed about the risks of the muscle slippage and diplopia. When the case came on for trial in 2003, expert witnesses argued over the timing and extent of the consent process. In his evidence on behalf of the patient, a leading ophthalmic surgeon from the UK said that the consent was neither adequate nor satisfactory. “I think the appropriate time to discuss the matter in detail is at a time when you have the relevant facts that allow you make up your mind and you have a discussion with the patient in an outpatient setting,” the patient’s expert told the court. For his part, one of the doctor’s experts acknowledged that by 2003 professional practice would require a surgeon to fully inform a patient about the risks and benefits of squint surgery well in advance of any operation and that all of this information would be documented in the notes. The expert added that in cases of elective surgery, the treating doctor would normally send a letter to the patient to explain the risks and benefits and to offer the patient the opportunity to seek a second opinion. At the time of the surgery in 1994, however, professional practice allowed surgeons to wait until the day of surgery to inform patients about the risks and benefits of the planned procedure. In his judgment, the trial judge dismissed the case against the hospital and treating doctor. In doing so, the judge accepted the evidence of the trainee surgeon that he had warned the patient about the risks and benefits of the surgery despite the absence of any record of those warnings and the timing of the warnings. In coming to that conclusion, the judge said that the patient was not a credible witness, largely because he thought the patient exaggerated the extent and effect of his diplopia. The patient then appealed his case to the Irish Supreme Court. In the appeal, lawyers for the patient withdrew his allegation that he was never informed about the risks and benefits of the strabismus surgery. Instead, the lawyers focused on the timing of the warning and asked the court to hold that the consent was invalid because it came too late. Lawyers for the doctor, however, submitted that the content and timing 46 “I think the appropriate time to discuss the matter in detail is at a time when you have the relevant facts that allow you make up your mind and you have a discussion with the patient in an outpatient setting” Leading ophthalmic surgeon from UK Legal Matters Take the time to talk to your patients by Paul McGinn EUROTIMES ESCRS PODCAST Listen to our podcasts at www.eurotimes.org Podcasts are also available on

47 of the warning was appropriate by the standards of 1994 and that the trial judge had not found otherwise. In finding for the hospital and doctor – and against the patient – the Irish Supreme Court looked at a number of Irish, UK, American, and Australian cases. From that review, the Irish court held that the consent process must be patient-centred, reveal all material risks, and be timed appropriately. Whether a consent process is patient- centred depends on a number of considerations: 1. It must respect the individual autonomy of the patient in the wider context of an emerging appreciation of basic human rights and human dignity that requires informed agreement to invasive treatment, except in cases of emergency or necessity. 2. Such respect redresses to some small degree, the risks of conflicts between interest and duty which a medical practitioner may sometimes face in favouring one healthcare procedure over another. 3. A legal obligation to provide warnings may sometimes help to redress the inherent inequality and power between a medical practitioner and a vulnerable patient. 4. Detailed warnings enable the patient to make the ultimate choice to undertake or refuse an invasive procedure, thereby reducing the likelihood for recriminations and litigation following the disappointment that can ensue after treatment. Material risks A consent process must disclose any “significant” risk that the doctor believes would affect the judgment of a reasonable patient. The court quoted from an earlier Irish case in which the judge explained that “the reasonable man, entitled as he must be to full information of material risks, does not have impossible expectations nor does he seek to impose impossible standards. He does not invoke only the wisdom of hindsight if things go wrong. He must be taken as needing medical practitioners to deliver on their medical expertise without excessive restraint or gross limitation on their ability to do so.” Timing of warning While upholding the appropriateness of the timing of the warning in this case, the Supreme Court made it clear that a doctor who relies only on a consent taken immediately before surgery does so at her or his own peril. “There are obvious reasons why, in the context of elective surgery, a warning given only shortly before an operation is undesirable,” the judge said. “A patient may be stressed, medicated or in pain in this period and may be less likely for one or more of these reasons to make a calm and reasoned decision in such circumstances…. While I have noted the views of a number of the experts to the effect that this practice of warning day patients on the day of their operation had its advantages, it seems to me that the disadvantages were far greater, including the possibility of an embittered patient later asserting that he was too stressed or in too much pain to understand what was said or to make a free decision and that he was thus effectively deprived of any choice.” Feature OS3/Novitrex®is the perfect combo system with unrestricted options in the anterior and posterior segments. It makes operating safer, simpler and more efficient. With the OS3 you have the future in your hands and can offer optimal care to your patients. Why is that? •OS3 was developed right from the outset uncompromisingly as a combined surgical platform.With one cassette for all operations, combined operations can be performed without interruption. •The OS3 double pump system enables you to choosebetween genuine peristaltic and genuine venturi aspiration at all times. In fact, you can switch in the middle of an operation with the pedal if required by the critical step in the operation. This gives greater safety and efficiency. •Patient and doctor benefit from a sophisticated microincision system with all its advantages. CO-MICS with 1.6 mm incision in the ante- rior segment, NovitreX3000 with 23G / 25G high-speed vitrect