May 2009 Issue

VOLUME 14 ISSUE 5 MAY 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 It is with great pleasure that I can contribute to this issue of EuroTimes which focuses on New Directions in Macular Disease. Readers of EuroTimes will get the opportunity to learn about some of the new developments in the treatment and diagnosis of AMD presented at the 9th EURETINA Congress which takes place in Nice this month (May), but also of other common or more uncommon retinal diseases. We will hear presentations on new pathways to interact with VEGF synthesis and data from a number of studies on other pathways away from VEGF. The results on anti-VEGF versus PDT treatments will probably be available. In addition, regarding treatment, a large number of approaches for the atrophic form of AMD are evaluated and we might have some preliminary results to give hope to our patients. There is an ongoing debate about the issue of funding because of the impact of the high cost of AMD drugs, the requirement for repeated treatments and the increasingly large patient population on health budgets. In the UK, the National Institute for Clinical Excellence (NICE) produced guidance on treatments which most purchasers of healthcare might follow (14 treatments reimbursed by the health system, the following being paid by the manufacturer). This is one way to go. Another way to go is to have more cooperation with the pharmaceutical companies and to look at less sophisticated therapies. But this is not a medical issue, it is a political issue and we must bear this in mind, because as doctors, the care of our patients must always come first and be our major concern. We have excellent data showing the importance and impact of treating and diagnosing AMD. Governments and health policy makers have this data. This data shows the real, including social cost, of treating these patients and if ophthalmologists are given the resources to preserve the vision of these patients, it will help ease the pressure on health budgets. Obviously, an independent elderly person is less of a burden on his/her family and society. Adaptive optics is very exciting and we can now see excellent images with which individual cells can be examined. Treatment and diagnosis will improve in the future as we learn more about the chemistry and function of specific cells. If a specific dysfunction of a precise metabolism in a cell is found it will be easier for us to prevent AMD in the future. This is our main goal. The next step is to link morphology and function. If a dysfunctioning cell is identified, the disturbed mechanism can be evaluated and its consequences in the function can be measured, then early AMD can be prevented. This is an exciting prospect and I hope that we will be hearing more about this and other developments both in EuroTimes and from the presentations at EURETINA. Gisele Soubrane MD, PhD, is chair of ophthalmology, University Department of Paris XI-Créteil. gisele.soubrane@chicreteil.fr Guest Editorial Gisele Soubrane MD, PhD Early diagnosis crucial to prevention of AMD Editorial May BARCELONA 2009 XXVII Congress of the ESCRS 12 – 16 September CCIB Congress Centre Barcelona Spain EuropEan SociEty of cataract & rEfractivE SurgEonS 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

2 16 Innovations help surgeons cope with complex cataract surgery 17 Managing posterior IOl dislocation 18 Near and distant vision better with monovision 20 Pure torsional phaco more effective than mixed mode Cataract Update 8 Cost of drugs for retinal diseases major obstacle 9 The importance of OCT in diabetic macular oedema diagnosis 10 Alternatives to modified laser treatment for DME discussed 12 study compares two drugs for treating DME with severe hard exudates Special Focus – New Directions in Macular Disease 10 Special Focus> 12 Special Focus> 16 Cataract> 20 Cataract> Contents Refractive Laser 29 New lAsIK ablation profile increases depth-of-field, presbyopia options 32 Initial results impressive for intraCOR treatment More Contents 26 same-day surgery for multifocal IOls has no extra risk, expert says 28 Excellent results with light Adjustable lens Refractive Lens Cover image: Confocal image of rat RPE layer two weeks after laser. A well-defined neovascular membrane labeled with Isolectin Ib4 (red) is detected below proliferating RPE cells (Phalloidin in green). New vessels are growing toward the subretinal space. Credit: National Eye Institute, National Institutes of Health

4 Contents 34 Bevacizumab effective treatment for neovascularisation in PK 35 study shows DAlK outcomes favourable at 12 months Cornea Update 37 Advantage for tafluprost is that it is available in a preservative-free preparation Glaucoma Update 39 Interview with sOE president Gabriel van Rij, MD, PhD Ocular Update 41 Practice Management 42 EU Matters 43 Outlook on Industry 44 In Your Good Books 47 letter from America Features 6 Newsmaker Interview 13 News in Brief 45 JCRs Highlights 45 Journal Watch 46 Industry News 48 Calendar Regulars 28 Refractive Lens 32 Refractive Laser > > 29 Refractive Laser 43 Feature > >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 EUROTIMES ESCRS ™ Published by The European Society of Cataract and Refractive Surgeons The Total Average NET Circulation for the 12 issues of EuroTimes distributed between 1 July 2007 and 30 June 2008 is 27,664 Winner of the PPAI Business-to-Business specialist Magazine of the Year 2007

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Recent years have seen a revolution in the treatment of vitreoretinal diseases, with the advent of new treatments which not only preserve but actually restore vision in eyes with degenerative macular diseases, and new diagnostic technologies for the diagnosis and management of retinal disorders in general. EURETINA president Prof José Cunha-Vaz MD spoke with EuroTimes contributing editor Roibeard O’hEineachain about his organisation and its role in facilitating the continuing evolution of the treatment of retinal disease and about the focus and scope of this year’s EURETINA Congress. ET: What can you tell us about this year’s EURETINA Congress? Cunha-Vaz: The main theme of the congress has always been the debate on vitreoretinal diseases. We have invited speakers who are experts in their areas to tell us what’s up to date and what’s new in retinal chorioretinal diseases, mainly around the macula because that is what’s most important for vision. We also have sessions concerning diabetic retinopathy, oncology, vascular diseases, and uveitis. There are two sessions on AMD because it’s a major issue at the moment; there is also a session on how to follow retinal diseases, how to monitor progression. ET: Will there be some highlights to watch for? Cunha-Vaz: There are so many things happening. There will be new developments in monitoring retinopathy, new drugs, new treatments, reports from trials with comparisons between different anti-VEGF agents for treatment of macular disease, and reports on other new drugs just coming out which may offer alternatives and also combination therapies. The big difficulty is still to tailor the treatment for the patient. For example, is lucentis the only solution for AMD? Do we need to complement it with other therapies? How early should we look for risk factors? There are so many issues. These are exciting times in retinal treatment and we are just at the point now where the veil is being lifted for the first time. We have five or six drugs coming up with clinical trials ongoing, but we still are fine-tuning the indications for the treatments and the regimens to use. Another aspect we are discovering is the systemic implications of these treatments. For too long, ophthalmologists have been isolating themselves away from the rest of the body. I think they have to come back into the mainstream of medicine. Ophthalmologists need to know if their patients have cardiovascular risk factors and are prone to stroke. These patients are at risk because of age. We are just beginning to understand the risks. People up to now have been used to the idea of doing it because avoiding blindness is such a priority and the treatments available were too few. ET: Attendance at the meeting has increased from 200 at your first meeting to 1500 at the most recent meeting. Do you think this is in part due to recent advances that have made previously untreatable diseases now treatable? Cunha-Vaz: There are a couple of reasons, the most important is that there are now treatments available, not only for the retinal subspecialists to use but also for general ophthalmologists, who now treat retinal disease. The next thing is organisation, the fact that Agenda is dealing with the congress makes things more efficient and makes attending the congress less difficult and provides better exposition of new ideas. Organisation is crucial. We have an office which we share with the EsCRs which has also expanded greatly under Agenda’s management. ET: Has EURETINA membership grown in tandem with that increased attendance? Cunha-Vaz: That is something that always takes longer and people need to identify reasons to become a member but we are improving dramatically. We have just signed a deal which will be announced at the Congress. Ophthalmologica, an international journal of ophthalmology will be the official journal of EURETINA and I will be taking over as editor in 2010. We will have to keep raising our profile as a scientific society. Many things are happening and the next president of EURETINA, Bill Aylward, will definitely pick it up. ET: One of your presentations at the meeting concerns monitoring of DR. Do you think that the new technologies now available will enable the earlier detection of changes in the macula, and do you think that earlier treatment will prevent, delay or slow progression? Cunha-Vaz: I think we are just reaching the stage where we can predict the patients that progress and develop complications. This has to be validated at the start of the disease in order to identify the ones that are going to progress rapidly to macular oedema or proliferative retinopathy. That is the challenge, but at least now we have the tools to test drugs and quantify their effects in an objective manner. Among people with early retinopathy only 15 per cent will get macular edema within a 10-year period and they need to be identified and followed more closely. ET: In his EURETINA lecture, Eberhart Zrenner MD, chairman of the European Vision Institute (EVI), will be addressing the fragmentary nature of research in Europe today. Do you foresee a greater integration of research efforts across Europe, and if so, how will this come about and what will it achieve? Cunha-Vaz: I foresee that and I’ve been fighting for that. I am one of the founding members of EVI and we need an institute with centres in each of the European countries. A big goal of anything that happens in Europe is really to take advantage of so much diversity and yet there is so much need for communication. This is the kind of thing we can offer probably better than any other continent. European countries haven’t worked together as closely as they should, perhaps because of the many wars that have happened here and it takes time for people to be confident that it is not so important to have wars. It is better if we demonstrate our power by working together and making our contributions, particularly, findings that can be very important for mankind. I also think it’s the duty of scientific societies, which are composed primarily of physicians, to invest in better research for the future in order to improve the quality of healthcare. Doctors go into medicine because they want to help their patients, and research is the way for us to increase the value of the care we provide. I also really think that Europe is improving dramatically in research. Before the war Europe led the world in research, during the 1940s and 1950s it lagged behind the Us and I think it is now our moment to be as good as the Us. ET: Is there anything else you would like to add about EURETINA or the upcoming congress? Cunha-Vaz: I would just say that there are new things every year and we are proud of the programme we have put together and Agenda has done a tremendous job. We also now have a scientific journal and an active website. There is so much happening that it is an exciting time not only to be an ophthalmologist but to be a retinal specialist and a member of EURETINA. cunhavaz@aibili.pt 6 José Cunha-Vaz Newsmaker interview… José Cunha-Vaz Investment in research key to improving quality of healthcare Newsmaker Interview New Directions in Macular Disease 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 “The main theme of the congress has always been the debate on vitreoretinal diseases. We have invited speakers who are experts in their areas to tell us what’s up to date and what’s new in retinal chorioretinal diseases, mainly around the macula because that is what’s most important for vision”

Howard Larkin in Atlanta ANTI-ANGIOGENIC compounds, including ranibizumab (lucentis, Genentech), pegaptanib (Macugen, Eyetech) and bevacizumab (Avastin, Genentech), have revolutionised the treatment of a wide range of retinal diseases involving neovascularisation. But as clinically effective as these drugs are, economic and regulatory obstacles still prevent them from reaching as many patients as they should. For the first time ever, these drugs can effectively make it possible to halt or reverse conditions such as wet age-related macular degeneration (AMD) and diabetic retinopathy in many patients, often partially restoring lost vision in the process. But the cost – more than $2,000 (€1,575) per ranibizumab dose – was raised by Tommaso Rossi MD at a joint symposium of the American Academy of Ophthalmology and the European society of Ophthalmology. On a Nationwide scale, the burden to National Health services and Government-funded insurance programmes, for ranibizumab, is almost prohibitive and would require dedicated funding, Dr Rossi said. “For the first time we are confronted with a social and economic issue we have not seen before. Can we afford it?” asked, Dr Rossi, who practices in Rome, Italy, and is a member of the advisory board of the Italian Retina society. Regulatory and legal issue approvals also compound the problem: Bevacizumab, which many preliminary clinical trials suggest is as effective as ranibizumab in treating AMD at about 1/10th the cost, is not approved by either the European Medicines Agency (EMEA) or the Us Food and Drug Administration (FDA) for any ocular indication, nor is it packaged for such use. As a result, many health insurers will not pay for it. And even if they do, physicians and hospitals that administer it may take on added legal liability in the event of an adverse patient outcome. similarly, ranibizumab and pegaptanib, while approved for exudative AMD, are not specifically approved for other ocular conditions, raising both reimbursement and liability questions. These economic and legal obstacles greatly complicate and in many cases limit the appropriate use of these drugs. squeezed by budget considerations, regulatory and insurance officials in every country have adopted a dizzying variety of payment guidelines, said stefano Piermarocchi MD, University of Padova, Italy. In many cases, these restrictions bear little rational relationship to the clinical evidence upon which they are supposedly based. In part, because it has been shown highly effective in treating AMD and is approved by both the EMEA and the FDA for this purpose, ranibizumab has been approved in several countries for full or partial reimbursement, Dr Piermarocchi noted. For example, in the UK, where it has also been recommended by the UK National Institute for Health and Clinical Excellence (NICE), ranibizumab is approved for payment for 14 injections. However, pegaptanib, which has also been approved by EMEA and FDA for AMD, is not approved for payment, perhaps because it is less effective. Neither has bevacizumab, even though NICE recognises the evidence suggesting its effectiveness and advocates randomised clinical trials in this area. Any use of any of these agents for conditions other than AMD is considered off-label and is not eligible for payment, Dr Piermarocchi said. The situation is even more complicated in Italy, Dr Piermarocchi reported. Italian officials take into account not only regulatory approvals but also the clinical recommendations of professional societies and standards of care based on scientific evidence in determining what drugs are reimbursable under the public insurance system. Both ranibizumab and pegaptanib are registered for treating AMD, but they are not unconditionally reimbursed. However, they are reimbursed only under certain clinical conditions and on a “payback” policy – if, after a certain given number of injections, the patient’s condition does not improve, the manufacturer must reimburse the hospital for the cost of the drugs. Further complicating the Italian scenario are regulations specifically authorising the use of bevacizumab for two off-label indications: exudative maculopathy and neovascular glaucoma, Dr Piermarocchi said. “The tricky part is that reimbursement covers not only AMD previously treated with bevacizumab and those cases who failed with the other registered drugs, but also any other disease that might potentially produce exudation, such as diabetic maculopathy or myopic CNV.” But while this appears to be a generous allowance, in fact the regulations limit reimbursable injections to three, even though this flies in the face of a large body of clinical evidence suggesting monthly or at least quarterly injections over a long period of time, Dr Piermarocchi noted. “Based on the published trials there is a low level of evidence for lucentis, a very low evidence level for Macugen and no data for Avastin,” [supporting a three-injection limit] the Italian Retina society reported in its official guidelines. In the Us, the reimbursement situation is somewhat better, but still muddled, Dr Piermarocchi said. The Us Centre for Medicare and Medicaid services, which sets overall policy for Medicare nationwide, approves payment for all three drugs for many indications. However, the private companies that administer Medicare in the 50 states are free to set their own reimbursement policies. some will reimburse for off-label use of bevacizumab as a front-line treatment for AMD, while others will pay only if the patient has failed on-label trials of approved drugs such as ranibizumab and pegaptanib. A few will not pay for bevacizumab at all. On top of that, hundreds of private insurers that cover most patients under age 65 have their own payment rules that are generally not subject to government oversight. Beyond reimbursement limits, use of any of these drugs off-label potentially exposes physicians and hospitals to greater malpractice liability, Dr Piermarocchi said. The use of Avastin instead of lucentis gives the plaintiff’s attorney “more ammunition”, he noted. If the patient does not do well and sues, the attorney is likely to portray the choice to use Avastin over lucentis as driven entirely by cost, choosing an unproven drug over one that not only has a proven track record, but has the endorsement of government regulators. However, Dr Piermarocchi does not believe this means that ophthalmologists should avoid off-label use of anti-angiogenic agents. The ethical, clinical and economic reasons for doing so are compelling. What ophthalmologists do need to do is give a more detailed and thorough informed consent, outlining the risks and benefits of treatment, and disclosing the regulatory and financial issues. This expended consent procedure should be followed not only when treating AMD with bevacizumab, but also when treating conditions other than AMD, such as diabetic maculopathy of myopic CNV, with ranibizumab and pegaptanib, as these are also considered off-label uses of approved drugs. “Even though this off-label use has no specific regulations governing it, it is entirely legal in both Europe and the United states,” he said. stefano.piermarocchi@unipd.it tommaso.rossi@usa.net 8 Stefano Piermarocchi Payment rules, regulatory hurdles complicate use of anti-VEGF drugs Special Focus New Directions in Macular Disease 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. Don’t Miss Outlook on Industry Page 43 “Based on the published trials there is a low level of evidence for Lucentis, a very low evidence level for Macugen and no data for Avastin” [supporting a three-injection limit] Italian Retina Society guidelines

Devon Schuyler in Atlanta IMAGING with optical coherence tomography (OCT) can identify at least six different patterns of diabetic macular oedema (DME). Identifying these distinct patterns may help ophthalmologists manage their patients because the different patterns may require individualised treatment regimens,” according to Peter K Kaiser MD, of the Cleveland Clinic in Ohio. A diagnosis of DME is made using binocular slit lamp biomicroscopy. After a clinical diagnosis is made, fluorescein angiography (FA) is very important to both confirm the diagnosis and provide a basis for treatment. Even more importantly, FA is used to identify areas of ischemia in the macula so that laser use can be avoided in those areas. FA identifies two forms of oedema: focal and diffuse. In focal oedema, the retinal thickening occurs around a cluster of microaneurysms. “For this, direct laser treatment to the leaking microaneurysms is beneficial. In diffuse oedema, the source of leakage is less obvious, and laser is less effective. The problem with FA is that the amount of leakage does not correlate with visual acuity or clinical outcomes. What’s more, FA does not illustrate vitreoretinal abnormalities, which may necessitate a different type of treatment. That’s why imaging with OCT is so valuable,” said Dr Kaiser, in a presentation at the annual meeting of the American Academy of Ophthalmology. The importance of OCT There are two ways to look at optical coherence tomograms, said Dr Kaiser. The first is a single-scan tomogram, which provides a cross-sectional view of the retina. The second is a retinal thickness map, which provides a topographical analysis of retinal thickness. “Many studies have shown that retinal thickness maps correlate well with clinical and fluorescein leakage, and more importantly, they correlate very well with decreased visual acuity. The thicker the retina, the worse the visual acuity,” he said. Dr Kaiser said that retinal thickness maps could be used to track disease progression and to evaluate the efficacy of treatments. The disadvantage of retinal thickness maps is that they don’t provide structural details or vitreomacular interactions. For that, the single- scan tomogram is still necessary, he said. single-scan tomograms reveal several distinct patterns of macular oedema, with differing prognoses and management. “It’s very important to be able to recognise these patterns on OCT,” he said. The most common pattern is sponge- like DME, which studies have reported as accounting for between 55 and 96 per cent of DME cases. sponge-like DME occurs when the outer layers of the retina absorb fluid, often compressing the inner retinal layers. “This particular pattern correlates very well with reduced visual acuity, and responds well to laser treatment,” he said. The next most-common pattern is diabetic cystoid macular oedema, which occurs in between 30 and 57 per cent of cases in clinical studies. This type of oedema, which generally begins in the outer layers of the retina, occurs when cysts grow and compress the remaining retinal tissue. “As the cysts grow, they begin to coalesce and give a dome- shaped profile to the fovea,” he said. Visual acuity is significantly worse when cysts are present, and laser treatment is often ineffective. Instead, ophthalmologists can opt to use experimental treatments such as steroids, anti-VEGF agents, or surgery. The next pattern is serous retinal detachment without posterior hyaloidal traction (PHT). This occurs in a very small number of patients, with an incidence ranging from none to 15 per cent in published reports. In serous retinal detachment, which is often not evident on ophthalmoscopic examination, the greatest accumulation of subretinal fluid occurs in the fovea. When the fluid gets resorbed, hard exudates may be deposited within the subretinal space. As with cystic patterns, laser treatment is usually ineffective and ophthalmologists may wish to use experimental treatments. The final pattern is DME due to PHT, which affects an estimated 16 per cent of patients with DME and can occur either with or without traction retinal detachment. About an eighth of cases display traction retinal detachment; the rest do not. Ophthalmologists often miss the DME due to PHT diagnosis on examination, especially when the hyaloid is only slightly detached from the retinal surface. “One of the clues is if you sort of see the sheen when you look in on a clinical exam. This ‘sheen’ may indicate traction, which can lead to traction retinal detachment. DME due to PHT does not respond to laser treatment. What’s more, it does not respond to any of our medical therapies, including anti-VEGF or steroid injections. Even though retinal thickness and macular oedema improve with these treatments, visual acuity does not until these patients are taken to the operating room and the traction is released with vitrectomy.” pkkaiser@aol.com 9 What ophthalmologists need to know about imaging in diabetic macular oedema Special Focus New Directions in Macular Disease 4C[6TCEKPIHQTOQUVCEEWTCVG6QVCN%QTPGCN2QYGTCPF#PVGTKQT%JCODGT&GRVJ +1.ECNEWNCVKQPDCUGFQP6QVCN%QTPGCN2QYGTYKVJPGYHQTOWNCHQTRQUV.#5+-CPFRQUV24-G[GU 'CU[VQWUG(CUV4GRGCVCDNG 2TQXKFGCJKIJGTUVCPFCTFQHECTG HQT[QWTTGHTCEVKXGCPFECVCTCEVRCVKGPVU 2TQOQVKQPCN%QFG#) C M Y CM MY CY CMY K GALILEI_09 A07G05.pdf 06.04.2009 22:36:51

Devon Schuyler in Atlanta REsEARCHERs are developing alternatives to the modified ETDRs (Early Treatment Diabetic Retinopathy study) laser treatment for diabetic macular oedema (DME), according to presentations at the annual AAO meeting. Potential alternatives include “light” photocoagulation, the subthreshold micropulse diode laser, the PAsCAl laser photocoagulation system (OptiMedica), and the mild macular grid technique. But with the exception of “light” photocoagulation, none of these techniques have been proven to work – and the mild macular grid technique appears to be less effective than the modified ETDRs laser. “Based on well-controlled, prospective randomised controlled trials and more than 35 years of clinical experience, laser photocoagulation remains the standard of care for diabetic macular oedema,” said Francesco Bandello MD, the chairman of the Department of Ophthalmology at the University of Udine in Italy. A technique with limitations The ETDRs treatment strategy for diabetic maculopathy involves treating areas of leaking microaneurysms using either the focal or grid technique. No treatment is administered within 500 μm of the centre of the fovea. The eye is retreated after three or four months for persistent or new clinically significant macular oedema. If retinal oedema persists and visual acuity is less than 20/40, treatment can be administered to within 300 μm of the centre of the fovea. Unfortunately, there are some limitations with laser treatment, said Dr Bandello. The ETDRs technique involves placing burns close to the centre of the macula, with potential complications that include progressive atrophy of the retinal pigment epithelium, enlargement of laser scars, central scotomas with decreased colour vision, tears in Bruch’s membrane leading to choroidal neovascularisation, and subretinal fibrosis. laser treatment for macular oedema has evolved over the years. The modified-grid technique used in ETDRs was introduced more than 15 years ago. In 2005, Dr Bandello and his colleagues published research on “light” photocoagulation, in which low levels of energy are employed to produce barely-visible burns at the level of the retinal pigment epithelium. Their 29-eye study suggested that “light” photocoagulation for macular oedema was equivalent to the “classic” laser technique. What’s more, “light” photocoagulation caused less central scotoma, improved efficacy of the outer blood-retina barrier, and proliferation of RPE cells. Subthreshold micropulse diode laser and PASCAL Other techniques being developed include the subthreshold micropulse diode laser and the PAsCAl laser delivery system. Both of these lasers employ shorter pulses than modified ETDRs, resulting in higher spatial localisation and less lateral spread. “In theory, these techniques should produce less side effects and have the same efficacy as the classic laser technique,” said Dr Bandello. Another presenter, Dominic A McHugh MD, of Kings College Hospital in london, UK, said that he now “routinely” uses MDl for macular oedema. “For mild-to-moderate oedema, I do micropulsed grid alone. Anything more severe than that, I do micropulsed grid plus Avastin, with quite good outcomes,” he said. He said that there are several clinical benefits of micropulsing. First, because the energy is low and so little tissue is destroyed, functional side effects such as visual field loss and reduced colour and night vision are minimal. second, limited choroidal thermal diffusion means that the treatment does not cause pain. Most importantly, the treatment “seems to retain the beneficial effects seen with suprathreshold therapy,” he said. He pointed to a study he published in 2007 with sivraprasad and colleagues, in which 25 eyes with untreated clinically significant macular oedema underwent micropulsed grid treatment. After an average of two treatments and three years of follow-up, visual acuity had stabilised in 92 per cent of patients and improved in four per cent. There were no laser-related side effects. Another technique that has been proposed is the mild macular grid technique. This involves placing mild, widely spaced burns throughout the macula. some burns are placed in retina that appears to be clinically normal. A meta-analysis published in 2007, however, revealed that the mild macular grid technique was less effective at 12 months in reducing retinal thickening on optical coherence tomography (OCT) compared with the modified ETDRs laser technique. Dr Bandello pointed out that OCT is unnecessary unless there is diagnostic uncertainty over whether clinically significant macular oedema is present. Eyes with a reading of more than 300 μm usually benefit from treatment, whereas those with a reading of less than 250 μm will not. He said that future treatments that combine laser therapy with medication might provide enhanced effectiveness with minimal collateral damage. In the meantime, “despite potential theoretical advantages offered by the new laser devices and treatment modalities, the modified ETDRs technique appears to be the most effective,” he said. francesco.bandello@uniud.it dmchughsecretary@live.co.uk 10 Researchers developing alternatives to modified laser treatment for diabetic maculopathy Special Focus New Directions in Macular Disease Exudative diabetic maculopathy Six months following micropulsed macular grid laser, the exudates have largely resolved. Note the lack of laser scars “In theory, these techniques should produce less side effects and have the same efficacy as the classic laser technique” Francesco Bandello MD Courtesy of Dominic A McHugh MD

Devon Schuyler in Atlanta A VARIETY of new implants that deliver corticosteroids to people with diabetic macular oedema (DME), provide an alternative to frequent injections, potentially reducing the risks of infection or retinal detachment. There are two fundamental approaches to drug delivery systems for the eye, said Baruch D Kuppermann, MD, a professor of ophthalmology and biomedical engineering at the Gavin Herbert Eye Institute at the University of California, Irvine. The first approach is reservoir implants, which provide good long-term drug delivery but may cause ocular side effects related to the drug itself or to suppression of native factor expression. The second is biodegradable inserts, which have the potential to cause fewer side effects but are potentially less effective. Most of the new systems use either fluocinolone acetonide or dexamethasone, which are far more potent than older corticosteroids such as cortisone and cortisol, and are also more potent than the commonly used intravitreal steroid triamcinolone acetonide. Reservoir implants A first-generation device that has been tested in DME is the Retisert implant (Bausch & lomb), which contains 0.59mg of fluocinolone acetonide. The device is surgically implanted through a 3.5mm incision and sutured to the eye wall, where it provides a relatively consistent delivery for about two and a half years. The initial dose is 0.6μg a day, which decreases over the first month to about 0.3-0.4 μg a day. The FDA approved Retisert for uveitis based on two clinical trials of 227 patients with chronic uveitis. Uveitis recurred in far more patients in the control group (45.8 per cent) than in the implant group (5.4 per cent) at one year. A phase 3 trial in 180 people with DME also produced promising results; statistically more people gained three or more lines of vision at three years compared with the standard of care. “Although DME showed a benefit, the company did not pursue that application because of the significant ocular side effects, primarily cataract and glaucoma,” said Dr Kupperman. Two major concerns with corticosteroids are glaucoma and cataracts. In the Retisert studies, significantly more people who received the implant required topical medication to lower intraocular pressure at one year (14 per cent vs. 11 per cent) and at three years (49 per cent vs. 20 per cent). surgical implantation of a filter also was much more common among people who received the implant than in those who did not (40 per cent vs. two per cent). Dr Kuppermann advised ophthalmologists to screen patients with Retisert implants regularly for glaucoma, especially after the first year and a half. Although the ideal screening schedule is unknown, he said that every two months is a logical approach. “These are eyes that are white and quiet, they look great, but then they come back in three months and their intraocular pressure is 50 mmHg and they have glaucomatous cupping,” he said. He added that cataracts are “nearly ubiquitous” in people using corticosteroid implants, affecting more than 95 per cent of patients in the first three years after implantation. Fortunately, both cataract and glaucoma surgery, which are typically complicated in patients with uveitis, are made much less complex in the presence of the Retisert implant due to its ability to effectively control postoperative inflammation. Medidur (Alimera) is a second-generation version of the Retisert fluocinolone acetonide implant (both were developed by the same company – PsiVida – before being licensed) that has yet to be approved. The narrow, 3.0mm long, cylindrical device can be implanted without surgery using a 25-gauge injector. It releases either 0.5 μg of fluocinolone acetonide a day for 18 months, or 0.2 μg a day for three years. The company has 900 patients with DME enrolled in two pivotal phase 3 trials. Biodegradable inserts Another device being developed is Posurdex (Allergan), a biodegradable implant in phase 3 trials that contains either 350 or 700 mcg of dexamethasone. The implant, which is made of a biodegradable copolymer, is injected into the vitreous cavity of the eye and releases the corticosteroid as it breaks down. The polymer in the Posurdex is poly- lactic-glycolic acid (PlGA), similar to what is in absorbable sutures, said Dr Kuppermann. The drug is released in a biphasic fashion, with very high doses for up to six weeks, followed by low but therapeutic doses out to six months or more. A phase 2 trial of 315 people with persistent DME revealed that significantly more of those receiving high-dose dexamethasone implants had improved vision compared with those under observation at six months. Two phase 3 trials are under way, one in patients with persistent macular oedema due to vein occlusion and the other in patients with persistent DME. Enrolment has been completed for the first trial, and “top-line data show a significant benefit,” he noted. A fourth device under development is the I-vation implant (surmodics), a corkscrew-like implant coated with triamcinolone and a polymer matrix. The device releases triamcinolone as the matrix breaks down. Researchers have enrolled 30 patients with DME in a phase 1, three-year trial. “It’s screwed into the eye without a surgical incision, and the conjunctiva is allowed to heal over it,” he said. Concerns remain some ophthal- mologists have been concerned about the altered pharma- cokinetics of drugs injected into vitrectomised eyes because drugs that are cleared more rapidly from the eye may not work as well. A rabbit study of Posurdex found no significant differences in retinal drug levels following vitrectomy, which suggests that the drug delivery system may take over the reservoir function of the vitreous. However, until drug delivery systems become available, injecting medications into vitrectomised eyes is still considered worthwhile. Dr Kuppermann concluded by saying that having various choices available may represent the best approach to treating patients with DME. “I expect that we’ll have various drug delivery options, with various drugs in them for various disease states, which hopefully will result in greater benefit of our patients.” bdkupper@uci.edu 11 Sustained-release steroid implants in development for diabetic macular oedema Special Focus Baruch D Kuppermann New Directions in Macular Disease

Devon Schuyler in Atlanta DIABETIC macular oedema (DME) with severe hard exudates responds better to triamcinolone than to bevacizumab (Avastin, Genentech), according to research presented at the AAO meeting. The research was carried out in the Department of Ophthalmology of Prof Moncef Khairallah, Fattouma Bourguiba University Hospital, Monastir, Tunisia. “Intravitreal triamcinolone is more effective than intravitreal bevacizumab in management of refractive diabetic macular oedema with severe hard exudates at six months,” said investigator salim Ben Yahia MD. Although previous work had found that the steroid was more effective than the anti- VEGF agent at reducing DME, only triamcinolone had been tested in cases of DME with severe hard exudates. “None of the previous published reports compared the effect of the two drugs on severe diabetic hard exudates, as in our study,” said Dr Ben Yahia. The prospective study included 48 consecutive patients with diabetes who had severe hard exudates involving the fovea. Exclusion criteria included previous treatment for DME, elevated intraocular pressure or a history of glaucoma, recent thrombo- embolic events or uncontrolled high blood pressure, or having only one eye. Participants were randomly assigned to a single intravitreal injection of either 4.0mg of triamcinolone or 1.25mg of bevacizumab in one eye. The injection was performed under sterile conditions under subconjunctival anaesthesia. “We used a 27-gauge needle, and the injection was performed in the temporal inferior quadrant,” said Dr Ben Yahia. Postoperative treatment consisted of the topical antibiotic ofloxacin applied four times a day for 15 days, and patients were examined on postoperative days one and seven and months one, three, and six. Colour fundus photographs were used to evaluate the presence and the severity of hard exudates in the macula. Improvements in visual acuity After at least six months’ follow-up, the average visual acuity had improved significantly (from 0.85 logMar to 0.65 logMar) in the triamcinolone group but remained unchanged (from 0.81 logMar to 0.82 logMar) in the bevacizumab group. In addition, the degree of improvement of best-corrected visual acuity was significantly higher in the triamcinolone group than in the bevacizumab group (0.2 vs. 0.0003). Complete resorption of hard exudates occurred more often in the triamcinolone group than in the bevacizumab group (59 per cent vs. 21 per cent). In addition, participants who had received bevacizumab were more likely to experience persistence or aggravation of hard exudates than those who had received triamcinolone (42 per cent vs. 13 per cent). One-quarter of the participants who had received triamcinolone experienced a significant increase in intraocular pressure, which was successfully managed in all cases using topical medication. None of the participants who received bevacizumab experienced a significant increase in intraocular pressure, and none of the participants in either group experienced complications such as cataract progression or endophthalmitis. “Recent studies have demonstrated that intravitreal triamcinolone acetonide is beneficial for reducing hard exudates, decreasing fluorescein leakage, and significantly improving visual acuity in patients with diabetic massive hard exudates,” said Dr Ben Yahia. Results with bevacizumab have been less consistent. For example, a recent report from the Pan-American Collaborative Retina study Group showed dramatic improvement in DME one month after intravitreal bevacizumab, with results lasting for up to six months. shimura and colleagues, however, found that intravitreal bevacizumab induced only a “mild” reduction of foveal thickness one month after the injection. Although triamcinolone appeared to be a superior treatment for DME with severe hard exudates, Dr Ben Yahia said that people with ocular hypertension or glaucoma should not receive the steroid. He also pointed out that cataract formation is a frequent complication of triamcinolone, although his own study was too brief to detect any increase. How triamcinolone may work Although the mechanism by which triamcinolone reduces hard exudates remains unknown, Dr Ben Yahia pointed out that corticosteroids have the ability to inhibit the arachidonic acid pathway, of which prostaglandin is a product. They have also been shown to down-regulate the production and expression of VEGF, he said. “Hard exudates probably resolved mainly as a consequence of reduction in leakage from multifocal capillary lesions, particularly microaneurysms,” he said. He added that the vasoconstrictive properties of triamcinolone might also modulate the retinal haemodynamics and increase capillary wall resistance, resulting in clinical disappearance of a proportion of microaneurysms. session panellist Alan C Bird MD, pointed out that worsening of exudates can mean that either the disease is getting worse or the oedema is getting better. “It’s not a very good indicator of severity of disease,” he said. Panellist Julia A Haller MD agreed with Dr Bird, saying that it was possible to have “very successful resolution of exudates and no improvement in visual acuity”. Dr Ben Yahia said that future studies should assess whether having more than one injection of triamcinolone will improve the results. salim.benyahia@rns.tn Alan.Bird@ucl.ac.uk jhaller@willseye.org Fundus photograph of eye taken six months after intravitreal injection of triamcinolone shows complete resorption of hard exudates Courtesy of Salim Ben Yahia MD 12 Salim Ben Yahia Triamcinolone more effective than bevacizumab for DME with severe hard exudates Special Focus New Directions in Macular Disease

13 News in Brief The John Henahan Prize is inspired by the memory of John Henahan, the visionary editor and guiding light of EuroTimes from 1996 to 2001. Ophthalmologists who are members of the ESCRS and who are under 40 years of age are eligible to apply for the prize. Entrants are invited to write a 1,000-word article on the theme: “My best patient; my worst patient.” Dr Emanuel Rosen, chairman ESCRS Publications Committee, Dr Jose Guell, medical editor, EuroTimes, Sean Henahan, editor, EuroTimes, Robert Henahan, contributing editor, EuroTimes and Paul McGinn, editor, EuroTimes will judge the entries. The winner will receive a travel bursary worth E1,000 to attend the XXVII Congress of the ESCRS in Barcelona, 2009 in September and will also be presented with a special trophy at the Young Ophthalmologists Programme in Barcelona. The winning entry will be published in the October edition of EuroTimes and on our website at www.eurotimes.org. Entries, which must be accompanied by an ESCRS membership number, should be sent to Colin Kerr, executive editor, EuroTimes at colin.kerr@escrs.org. The decision of the judges is final and no correspondence will be considered once they have announced the winner. Please note that only entries submitted by email to the address below will be considered and no typed manuscripts will be considered. The closing date for entries is Friday June 26, 2009. Devon Schuyler in Atlanta QUAlITY of vision is just as good with deep anterior lamellar keratoplasty (DAlK) as with penetrating keratoplasty (PK) or keratoconus, but only if Descemet’s membrane (DM) is exposed in DAlK, reports luigi Fontana MD of Bologna, Italy. “Descemet’s membrane is the optimal plane of dissection in the course of DAlK, allowing visual function comparable to PK and the lowest risk of interface opacities,” he said. The prospective study included 81 eyes in 81 patients aged 18 to 50 years with keratoconus. Patients were included if their sutures were out and they had no postoperative complications, a manifest refraction spherical equivalent of 8.0 D or less, astigmatism of 6.0 D or less, and follow-up of at least 18 months. Twenty-one people underwent PK, 28 underwent DAlK with DM baring, and 32 underwent DAlK without DM baring. Uncorrected VA was comparable in all three treatment groups. Best-corrected acuities were comparable in the DAlK with DM baring group and the PK group, and results were worse in the DAlK without DM baring group. There were traces of opacity in 35 per cent of the DAlK without DM baring eyes, versus “very few” of the DAlK with DM baring eyes. Mild opacities occurred in nine per cent of the DAlK without DM baring eyes, versus less than four per cent of the DAlK with DM baring eyes. “No patient had gross opacity of the interface postoperatively,” said Dr Fontana. luigi.fontana@ausl.bologna.it Post-cataract DME higher in diabetic retinopathy patients DALK with exposed Descemet’s membrane produces good quality of vision Roibeard O’hEineachain in Berlin EYEs with diabetic macular oedema appear to have more than a three- fold greater increase in foveal thickness than eyes without diabetic retinopathy during the first three months following cataract surgery, although the oedema tends to subside in the months that follow. “The degree of oedema in diabetic retinopathy patients increases until three months after cataract surgery, but thereafter decreases gradually. Grade of the oedema also worsens until three months, but certain per cent of diabetic macular oedema that occurs after surgery resolves spontaneously. These changes are more prominent in eyes with diabetic retinopathy,” said Ken Hayashi MD, Hayashi Eye Hospital, Fukuoka, Japan. The study involved 34 eyes of diabetic patients with diabetic retinopathy and 34 eyes of diabetic patients without retinopathy who underwent cataract surgery. The two groups were similar with regard to age and sex and foveal thickness but the diabetic retinopathy group had been diabetic for significantly longer and had significantly higher HbA1c values. At three months’ follow-up, OCT measurements showed that foveal thickness increased by 20.3 per cent in the diabetic retinopathy group, compared to only 6.0 per cent in the group without diabetic retinopathy (P=0.0295). However the oedema decreased gradually after three months, and by six months there was no significant difference between the groups. similarly, the mean macular volume was significantly higher at three months in the diabetic retinopathy group with a mean value of 2.76mm3, compared to 2.49mm3 in the non-diabetic retinopathy group. In addition, the grade of macular oedema worsened in eight eyes (23.5 per cent) in the diabetic retinopathy group, and only one eye (2.9 per cent) in the group without diabetic retinopathy. The incidence of the complication after surgery was significantly greater in the diabetic retinopathy group (P=0.0272). However, the oedema that occurred after surgery resolved spontaneously in three cases (33.3 per cent). hayashi-ken@hayashi.or.jp Ken Hayashi

During the XXVII Congress of the ESCRSCCIB Congress Centre, Barcelona, Spain Congress Venue General Information Keynote Lectures CCIB (Centre de Convencions Internacional de Barcelona), Pl. Llevant, 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 availablewww.wcpos.org

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 1 Room 2 Room 3Room 1 Room 2 Room 3 Opening & Welcome Free Papers (Non Strabismus) Ch: David Granet Ch: Ken Nischal Free Papers (Strabismus) Ch: David Granet Ch: Ken Nischal The Orbit Ch: Yassir Abou-Rayyah Ch: James Katowitz LIDS Ch: Dominique Bremond Optic Neuritis in Children Ch: Richard Gardner Visual Rehabilitation of the Poorly Seeing Child Ch: lea Hyvarinen Strabismus Re-do Strategies Ch: steve Kraft Application of Telemedicine Ch: Gene Helveston (TBC) Thyroid Eye Disease Ch: David Granet Paediatric External Diseases Ch: Yee Fong Choong 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 Glaucoma Ch: Alicia serra- Castanera Ch: Nicola Freeman Paediatric Anaesthesia Ch: Richard Martin Non-Accidental Injury Ch: Alex levin Strabismus Techniques Ch: Doran Neuman Genetics Ch: Eduardo silva Ch: Elias Traboulsi Close of Congress: My World, My Way Ch: Marilyn Miller Keynote Lecture Jack Kanski Keynote Lecture Ken Wright Closing Reception 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 Strabismus Syndromes Ch: Ramesh Kekunnaya Ch: Cumhur sener Retinoblastoma Ch: Brenda Gallie (TBC) Ch: Arun singh Exotropia Ch: Kanxing Zhao 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

Cheryl Guttman in Berlin OPHTHAlMOlOGIsTs’ ingenuity has been the source of numerous simple innovations for overcoming difficult intraoperative situations. A series of speakers described methods for improving intraocular visualisation and managing cases involving a small pupil or shallow anterior chamber during a special session of the XXVI Congress of the EsCRs. Bong-Hyun Kim, MD, seer and Partner Eye Institute, seoul, south Korea, demonstrated the intraocular mirror he designed that is useful for intraoperative viewing of structures behind the iris and the corneal endothelial surface. The device is known as the BH Kim Intraocular Mirror and is commercially available from Katena Instruments. “Inability to see clinically relevant structures behind the iris is one of the challenges in cataract surgery that can lead to a number of problems, including missed cortical remnants at the lens equatorial region, inability to judge the extent of zonular damage, and uncertainty about IOl positioning. The mirror I designed is a simple and useful tool, enabling surgeons to visually inspect remote areas of the eye that are not visible through the operating microscope alone. To my knowledge, it is also the first instrument that allows demonstration of corneal endothelial damage intraoperatively,” said Dr Kim. Dr Kim adopted his idea for an intraocular mirror from the field of dentistry, modifying the intra-oral mirror for ophthalmic use. The mirror is composed of a round head, a shank, and a handle. The head measures 2.5mm in diameter, 0.3mm in thickness, and is made of highly reflective stainless steel. Use of the instrument is straightforward. After injecting viscoelastic into the anterior chamber and behind the iris, the mirror is inserted and rotated or tilted as necessary to provide visualisation of otherwise obscured structures. Viewing of corneal endothelial defects is accomplished with reflection or retroillumination. In a series of slides and videos, Dr Kim demonstrated use of the mirror in various situations, including for ascertaining IOl positioning in an eye with a small pupil, determining the extent of zonular dehiscence, and for locating the IOl haptics in an eye undergoing explantation of an opacified IOl. “When removing an IOl, release of the adhesion between the haptics and the capsular bag is a critical step. However, if the surgeon cannot determine the exact position of the haptics, a zonular break is likely to occur. This mirror addresses that problem so that the haptic can be safely and easily separated from the capsule,” he explained. The ability of the mirror to identify corneal endothelial damage was demonstrated using two intraoperative views taken simultaneously, one with direct viewing where no damage was recognisable, and one with retro- illumination using the mirror. Simple and safe pupil expander A number of techniques and devices have been developed to address the problem of small pupils. The Malyugin Ring, an injectable temporary pupil expansion device, is the latest entry. Boris Malyugin, MD, PhD, s Fyodorov Eye Microsurgery Complex, Moscow, Russia, described the concept of his invention and presented data from studies that confirm its safety. “This iris ring is an effective tool for expanding the pupil without overly stretching and traumatising the iris tissue. It protects the pupillary margin and iris sphincter during surgery and allows the pupil to return to its normal shape, size and function postoperatively,” Dr Malyugin told attendees. The Malyugin Ring is constructed of 5-0 Polypropylene and features four circular loops (scrolls) that hold the iris at equidistant locations. Each of the scrolls catches the iris margin, retracting the iris to expand the pupil diameter. Malyugin Ring system (Microsurgical Technology Inc.) consists of a holder containing the ring and inserter. The inserter is disposable and it is used to load and introduce the ring into the eye and also to easily remove the implant at case completion. As the collapsible Malyugin Ring is introduced, the distal scroll catches the pupillary margin. lateral scrolls of the expanding device either simultaneously catch the opposite sides of the pupil or the surgeon manually positions them together with the proximal scroll. “Using this ring, surgeons can perform coaxial or bi-manual phaco without having their movements during irrigation and aspiration or lens implantation impeded,” noted Dr Malyugin. Dr Malyugin assessed the clinical performance of the device in a study including 38 eyes of 37 patients. The patients had a mean age of 71 years and mean nuclear density of 2.9. All were unresponsive to conventional pupil dilation techniques. Ocular comorbidities in the group included glaucoma, pseudoexfoliation, diabetes, and uveitis. The eyes were implanted with various types of hydrophilic acrylic IOls. Phaco parameters, including mean operative time (19.2 min), ultrasound time (13.1 sec), ultrasound power (17 per cent), and irrigation fluid volume (98.7ml), were not statistically different compared with a normal population. There were some complications, with transitory IOP rise being the most common, occurring in six eyes. However, mean IOP was 16.2 mmHg preoperatively and 15.7 mmHg at one month after surgery. Three eyes with rigid fibrotic pupils experienced a pupillary margin microtear, and microhyphema occurred in one eye, but these were clinically insignificant findings. Mean endothelial cell loss at six months was 7.8 per cent and the BCVA results showed the patients benefited with a dramatic postoperative improvement. Solution for shallow chambers There are many ocular conditions and patient-related factors that increase the likelihood of a shallow anterior chamber. In eyes with this finding, the cataract surgeon faces multiple challenges, including difficulty creating the incision, performing capsulorhexis, and filling the chamber with air and viscoelastic material. The risk of endothelial damage is also increased. One approach to this problem is the use of blind core vitrectomy through the pars plana. However, many cataract surgeons, whose experience is limited to the anterior chamber, do not have the expertise to perform this technique that can be especially challenging since the cataract impedes posterior segment visualisation. Possible complications of vitrectomy include bleeding, wound leaks, vitreous incarceration and endophthalmitis, said Zsolt Biro, MD, University of Pécs Medical school, Hungary. According to Dr Biro, oculopression is a safe and simple alternative for deepening a shallow anterior chamber. “Oculopression, introduced by Prof Daniel Vorosmarthy in the 1960s, was widely used in the eras of intracapsular and extracapsular cataract extraction, but was forgotten when phacoemulsification emerged. However, it still has a useful role. Oculopression can significantly deepen the anterior chamber in most eyes to allow safer surgery and decrease the risk of endothelial cell damage that can lead to corneal decompensation,” Dr Biro said. “Even if the amount of deepening achieved is more limited, it still becomes easier to fill the anterior chamber with viscoelastic after oculopression so that the surgery becomes easier and safer.” The oculopression is applied using either a Vorosmarthy type device (with a manometer) or a Honan balloon (no manometer) for 10 minutes. Then, surgeons must wait 15 to 20 minutes before beginning the case. Application of oculopression pushes fluid away from the anterior chamber and the vitreous cavity. Once the pressure is removed, the fluid fills the anterior chamber first, causing it to deepen. The waiting period allows the redistribution to occur, Dr Biro explained. “For surgeons operating under topical anaesthesia, the oculopression can be performed safely without peribulbar or retrobulbar anaesthesia. Heart rate and oxygen saturation are monitored with an electrocardiogram and pulsoximetry,” he noted. To demonstrate the benefit of oculopression, Dr Biro measured the anterior chamber depth using the Visante OCT model 1000 (Carl Zeiss) or the Ocuscan RxP (Alcon) ultrasound device using the noncontact technique in a series of 30 eyes undergoing oculopression with a Honan balloon. At baseline, the anterior chamber depth and axial length were 2.318mm and 23.496mm, respectively. Immediately after balloon removal, the anterior chamber depth had increased to 2.245mm and axial length was 23.455mm. At the end of the 15-minute waiting period, the anterior chamber depth was 3.075mm and axial length was 23.482mm. nunsusul@yahoo.co.kr boris.malyugin@gmail.com zsolt.biro@aok.pte.hu 16 Zsolt BiroBoris MalyuginBong-Hyun Kim Solving the challenges of complex cataract surgery Cataract Update Surgical case of the patient with cataract complicated by pseudoexfoliative syndrome and small pupil Courtesy of Boris Malyugin MD, PhD

Cheryl Guttman in Atlanta WHETHER a dislocated posterior chamber IOl is explanted and exchanged or managed by repositioning with suturing to the sclera or iris, it appears that excellent visual outcomes can be achieved overall, according to research presented at the annual meeting of the American Academy of Ophthalmology. “Our findings indicate surgeons should follow an individualised approach to the management of a dislocated IOl for each patient, taking into account the advantages and disadvantages of each technique in the context of lens, patient, and surgeon- related factors to decide which option is best in the given situation,” said Joshua Teichman, McMaster University, Hamilton, Ontario, Canada. Dr Teichman reported outcomes from a retrospective study comparing groups of eyes that underwent IOl exchange (162 eyes) or sutured repositioning (144 eyes) for management of a dislocated IOl. The surgeries were performed by a number of surgeons at different centres between 1995 and 2008. “The fact that this is a pooled analysis of cases from multiple cataract surgeons at different sites improves the external validity, or generalisability, of the results and makes it more of a ‘real world’ study,” said Dr Teichman. Mean follow-up was eight months for eyes that had IOl exchange and 10.6 months for the pooled repositioning group as well as in those undergoing scleral-suturing and iris-suturing IOl surgery. A comparison of the baseline characteristics of patients in the IOl exchange and repositioning groups showed a statistically significant difference in their mean age with the IOl exchange patients being older than those having a repositioned IOl, 74 vs. 70 years. However, the investigators attributed this difference to the retrospective nature of the study, and expected it would resolve as more patients were added to the series. In both groups, the most common location of the dislocated IOl was in the capsular bag, followed by the ciliary sulcus. However, there were anterior chamber lenses in the IOl exchange group only, as well as a higher proportion of dislocations into the vitreous. Analyses of adjunctive procedures performed during management of the dislocated IOl showed some significant differences between the IOl exchange and sutured repositioning groups. In both groups, anterior vitrectomy was the most common adjunctive procedure performed, but almost twice as many eyes in the IOl exchange group compared with the repositioning group required anterior vitrectomy, 52 per cent vs. 29 per cent, and the difference was statistically significant. Pars plana vitrectomy was performed in about 20 per cent of eyes in both groups, while the rate of pupilloplasty was twofold higher in the IOl exchange group compared with the eyes that had IOl repositioning, 10 per cent vs. five per cent. Various types of glaucoma procedures were performed in almost 10 per cent of eyes undergoing IOl exchange and in seven per cent of eyes having a repositioned IOl. About five per cent of the repositioning procedures involved the use of a capsular tension segment or capsular tension ring, whereas no capsular tension device was used in eyes that underwent IOl exchange. There were few intraoperative complications. In the IOl exchange group, vitreous haemorrhage occurred in two eyes, and one eye had a haemorrhage from the site of haptic fibrosis. Among eyes undergoing a sutured repositioning procedure, there was one vitreous haemorrhage, which necessitated stopping the procedure, and choroidal haemorrhage developed in one eye. At last follow-up, mean BCVA had improved significantly from preoperatively in both eyes that underwent IOl exchange, from 20/250 to 20/70, and in the sutured repositioning group, from 20/200 to 20/70. Few complications Transient IOP rise was the most common complication for both the IOl exchange (14.2 per cent) and repositioning (11.1 per cent) groups. Wound leak occurred in a significantly higher percentage of eyes undergoing IOl exchange compared with sutured repositioning (3.1 per cent vs. zero per cent). serious complications that occurred only after IOl exchange included three cases of retinal detachment and one case of endophthalmitis. “The association between these events and IOl exchange can be explained by the greater intraocular manipulations occurring during the exchange procedure,” Dr Teichman said. Redislocation was a significantly more common problem after IOl sutured repositioning than in the IOl exchange group, 6.9 per cent vs. 1.9 per cent. In addition, a significantly higher proportion of eyes with a sutured repositioned IOl required YAG capsulotomy for posterior capsule opacification compared with the IOl exchange group, 4.9 per cent vs. zero per cent. Five eyes that underwent IOl repositioning initially eventually had an IOl exchange procedure. The overall favourable outcomes achieved in the hands of multiple surgeons also indicates that with proper technique and vitreous management, anterior segment surgeons are able to successfully manage these patients, he noted. Iris-suturing vs. scleral suturing In a follow-up presentation, Jennifer Calafati MD, University of Toronto, discussed findings from subgroup analyses comparing outcomes of eyes that underwent IOl repositioning with iris-suturing (85 eyes) vs. scleral-suturing (59 eyes). Preoperatively, mean BCVA was 20/150 in the iris-suturing subgroup and 20/300 in eyes that underwent scleral suturing. However, the mean values were not significantly different. Regardless of which suturing technique was used to fix the repositioned IOl, mean BCVA improved significantly, and the difference between groups was not statistically significant. Achieved mean BCVA was 20/70 in the iris-sutured group and 20/63 in eyes with a scleral-sutured repositioned IOl. As in the overall sutured repositioning group, transient IOP elevation remained the most common post-op complication in each subgroup. However, eyes with a scleral-sutured IOl experienced a twofold higher rate of IOP elevation compared with the scleral-sutured subgroup, 15 per cent vs. eight per cent, respectively. IOl redislocation occurred at an identical rate (seven per cent) in both subgroups. Rates of other postoperative complications did not exceed five per cent for any one type of event, but the profile of these complications differed between the two groups. “Among eyes that had the repositioned IOl sutured to the iris, cystoid macular oedema, pseudophakic bullous keratopathy and iris haemorrhage were among the complications observed. Worsening of glaucoma and transient hypotony were noted after scleral suturing of the repositioned IOl,” said Dr Calafati. Jennifer.calafati@hotmail.com josh.teichman@gmail.com 17 “The fact that this is a pooled analysis of cases from multiple cataract surgeons at different sites improves the external validity, or generalisability, of the results and makes it more of a ‘real world’ study” Joshua Teichman Techniques for managing posterior IOL dislocation distinguishable mainly by complication profiles Cataract Update Joshua TeichmanJennifer Calafati Check it out on http://myeurotimes.blogspot.com for a unique online view on the world of ophthalmology EuroTimes now has its own Blog!

Roibeard O’hEineachain in Berlin MONOVIsION is an effective means of providing spectacle independence to cataract patients and presbyopes and may be more effective than the older types of multifocal IOls, according to studies presented at the XXVI Congress of the EsCRs. “Pseudophakic monovision is a more effective approach for presbyopia in patients over 60 years of age. The key to success is careful patient selection,” said Kimiya shimizu MD PhD, Kitasato University Hospital, sagamihara, Kanagawa, Japan. In a study involving 104 cataract patients, those who underwent bilateral implantation of monofocal IOls, with monovision as the goal, had better near and distance visual acuity, greater spectacle independence and higher satisfaction with their vision than those who underwent bilateral implantation of Array® multifocal IOls (sA40N, AMO), Dr shimizu said. The monovision group included 82 patients who ranged in age from 49 to 87 years, he noted. Their target refraction was emmetropia in their dominant eye and -2.0 D in their non- dominant eye. The patients in the multifocal group ranged in age from 54 to 88 years and their target refraction was emmetropia for both eyes, he added. After a follow- up of at least one year, the mean spherical equivalent was +0.14 D in the multifocal IOl group, and -0.10 D in the dominant eyes of the monovision group. The mean difference between the spherical equivalents dominant and non-dominant eyes of the monovision patients was 2.27 D. Near and distant vision better with monovision Dr shimizu noted that monovision provided better near and distance visual acuity than multifocal IOls. The mean binocular near visual acuity was 20/25 in the monovision group, compared to 20/33 in the multifocal group. In both groups, the mean distance visual acuity was 20/20 or better. In addition, the reading speed of the monovision group was significantly faster than that of the multifocal group at font sizes equivalent to newsprint (J4), J5 Revised Jaeger standard print, or smaller. Moreover, spectacle dependence was lower in subjects with pseudophakic monovision (17 per cent) than in those with multifocal IOls (34 per cent). scotopic contrast sensitivity was also significantly better in the monovision group than the multifocal group at spatial frequencies from 1.0 cycles per degree to 8.0 cycles per degree, Dr shimizu continued. Furthermore, in their responses to a questionnaire regarding visual satisfaction, 85 per cent in the monovision group indicated that they were satisfied with their outcomes, compared to only 77 per cent in the multifocal group. In both groups, the median value of near stereopsis was in the normal range. However, 18 per cent of monovision patients had results below the normal range on the Titmus stereo test, compared to only nine per cent of multifocal group. “Although there is a reduction of stereopsis, near visual acuity and contrast sensitivity is better with monovision. It also has the advantage of not being dependent on pupil diameter and additional correction is easily achieved if necessary,” Dr shimizu added. IOL designer’s personal monovision experience In another presentation at the Berlin congress, sverker Norrby PhD, an IOl designer for AMO, gave a firsthand account of how monovision gave him good enough near and distant visual acuity for all but the most demanding of distant visual tasks. Dr Norrby noted how he was originally born with anisometropia, with a disparity between the spherical error of his two eyes of around 4 D. He said that although prior to undergoing cataract surgery he wore glasses for most activities, he could also often do without them. When he developed a cataract he opted for monovision with bilateral implantation of Tecnis® (AMO) IOls. He performed his own IOl power calculation, using an exact ray-tracing algorithm that incorporates corneal topography, axial length, pupil size, IOl design and IOl position. The expected IOl position was in turn based on the Rostock formula, which was derived on a data set by regression of pre-op data against actually measured post-op ACD. In his right eye, Dr Norrby underwent implantation of a 19.0 D Tecnis IOl, with an expected postoperative spherical equivalent of -0.6 D. In his left eye he underwent implantation of an 18.0 D lens with an expected spherical equivalent of -3.31 D. At three months’ follow-up his spherical equivalent in his right eye was slightly more myopic than expected, at about -1.0 D, while his left eye was very close to target at -3.38 D. However, he noted that his unexpected postoperative refractive error in his right eye actually provided him with good general purpose vision. “In the end it turned out fortunate that my right eye was more myopic. After my second operation I could read without glasses the very same day. I could also read a menu in a dimly lit restaurant no problem. And to my surprise, I could also work with the computer despite the fact that the screen is not in focus for either eye. Dr Norrby said the occasions when he still wears glasses now include times when he is driving in unfamiliar areas and may have to read road signs and also when he is watching television with subtitles. He added that as he gave his presentation he was able to read his notes from the laptop screen and clearly see the audience without glasses. However, he said that when he attends congress sessions he uses glasses which correct the slight myopia of his right eye, but leave his more highly myopic left eye uncorrected, so that he can both see the presentations and read the programme book. He added that his uncorrected vision has also proved sufficient for manual tasks that require good hand/eye coordination, such as hitting a nail on the head with a hammer. Moreover, he pointed out that despite some aniseikonia he is able to fuse his left and right eye images sufficiently for stereopsis when looking through a pair of binoculars or into a microscope. “But my golf has not improved,” he cautioned. kos@med.kitasato-u.ac.jp sverker.norrby@amo-inc.com 18 Kimiya Shimizu Monovision remains a good option for presbyopes Cataract Update

Stefanie Petrou Binder MD in Berlin TORsIONAl ultrasound is more surgically efficient and performs even better than blending different ultrasound modes, according to David Allen MD, sunderland Eye Infirmary, sunderland, UK, who compared the use of torsional and longitudinal phacoemulsification within the same lens, to determine how to optimally implement combined phaco modes. Dr Allen performed 100 standard cataract surgeries in which he emulsified half the lens with pure torsional phaco using the OZil hand piece (Alcon), and the other half with mixed torsional/ longitudinal ultrasound. He performed cataract surgery with a standard technique using torsional phaco through a 2.2mm incision using the 0.9mm 45 degree Kelman mini-flared tip. “This study sets out to compare these two strategies and note any difference, because one might expect that if you were using a ‘heavy-footed’ technique that much more energy would get into the eye and you would need to lighten it up by adding a bit of longitudinal phaco. In fact, the trial showed that pure torsional phaco alone was more efficient,” he said in a presentation at the XXVI Congress of the EsCRs in Berlin. The investigation included 100 cataracts of all grades, except for very soft cataracts. Dr Allen used the stop and chop technique, which was suitable for this particular investigation in which the nuclei needed to be broken down halfway using each phaco mode. Dr Allen used the same fluidics for each lens half. For one half he implemented 20ms of longitudinal power followed by 80ms of pure torsional, which was the standard way that the software worked, he explained. The other half used continuous pure torsional. He recorded the amount of Bss used (using a precision balance attached to the Bss bottle) and the cumulative dissipated energy. subjective followability and turbulence was evaluated for each half. The average cumulative dissipated energy of the nuclear halves emulsified by blended modes was 2.74, and 2.37 for the pure torsional phaco halves. The difference was very statistically significant (P = 0.001), which was surprising, Dr Allen noted. Balanced saline solution use was also slightly less in the torsional group compared to the blended group, at 9.00ml and 9.67ml, respectively, but was not statistically significant, he observed. Dr Allen performed an alternative analysis in which each nucleus was its own control, by assessing the ratio of the cumulative dissipated energy spent in the hemi-nucleus of the same cataract within each phaco mode. The ratio of blended phaco/pure torsional phaco for each eye individually gave similar results. The mean cumulative dissipated energy ratio of blend/torsional was 1.24, and the mean Bss ratio of blended/torsional was 1.18. There was no apparent pattern with respect to cataract hardness, if you took the total cumulative dissipated energy for each cataract as a proxy for hardness, he noted. “Torsional phaco has been available to evaluators for over three years, and on the market for about two, he said. Initially we saw this new technology as a very efficient modification of traditional phaco using existing surgical technique. More recently, we have come to realise that its best potential can be achieved by slight changes in technique to maximise the surgical and patient benefits of this technology.” One of the main issues that concerned some of the surgeons who attended Dr Allen’s presentation dealt with which needle to use with torsional phaco. Dr Allen had reported at the XXV congress of the EsCRs in stockholm 2007 that the 45° mini-flare Kelman was best for torsional phaco. It has a slight flare at the tip that is not as much as the standard flare, and has a 0.9mm external diameter. “Initially many surgeons found that the needle tended to clog when dealing with very hard nuclei. In order to overcome this, it was recommended to add some longitudinal phaco to the torsional, since relatively high power and low vacuum would break off a piece of nucleus and it would lodge in the slight taper. Because all the effect of torsional phaco is on the outside there was no additional emulsification while the piece was lodged within the constriction of the needle, unless longitudinal phaco is added,” he said. As part of the process of learning how to optimise torsional phaco, surgeons are actually now using power earlier and more liberally, Dr Allen noted. The reduced thermal profile, absent repulsion, and reduced cavitation/free radical production makes this concept safe. There is very little repulsion and therefore better followability, reduced potential for turbulence, and increased cutting efficiency. The reduced thermal profile allows the use of continuous torsional modes, which ultimately increase surgical efficiency. “We are no longer afraid of putting our foot down on the accelerator with torsional phaco as we were with longitudinal phaco. Using pure torsional phaco, even “heavy-footed”, is more efficient than blending with a small amount of longitudinal. The 45 degree Kelman mini-flared tip does not require the constant blending of torsional and longitudinal phaco modes in order to be surgically effective.” allen401@btinternet.com Nucleus divided equally so each half can be removed with different settings 20 David Allen Torsional phaco is more efficient than mixed mode, even if you’re heavy-footed Cataract Update “In fact, the trial showed that pure torsional phaco alone was more efficient” Courtesy of David Allen MD

BARCELONA 2009 XXVII Congress of the ESCRS 12 – 16 September CCIB Congress Centre Barcelona Spain EuropEan SociEty of cataract & rEfractivE SurgEonS Now available online: n Preliminary Programme n Registration n Hotel Reservations www.escrs.org

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 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 E. Buckley USA 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 P. Khaw UK 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 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 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 eSCrS/WCpOS SympOSium main SympOSia BARCELONA 2009 XXVII Congress of the ESCRS

reFraCtiVe SurGery didaCtiC COurSe CLiniCaL reSearCH SympOSia Saturday 12 September 08.30 – 17.30 part 1 08.30 J.T. Holladay USA Corneal topography and IOl power calculation 08.55 D.S. Siganos GREECE Patient selection and preoperative preparation 09.10 T. Kohnen GERMANY Incisional and coagulative corneal procedures: Principles, technique and results 09.20 G. Kymionis GREECE lasers in refractive surgery 09.35 J. Krumeich GERMANY Overview of microkeratomes 09.55 R. Bellucci ITALY lAsIK - surgical technique 10.15 Break 10.35 T. Seiler SWITZERLAND surface Ablation Techniques (sATs): surgical technique 10.55 D. Epstein SWITZERLAND Results of corneal refractive surgery 11.15 J. Colin FRANCE Intrastromal corneal implants 11.25 A. Marinho PORTUGAL Overview of phakic IOls 11.45 E. Rosen UK Refractive lens Exchange 12.05 O. Findl UK Multifocal IOls 12.20 G. Grabner AUSTRIA Presbyopia 12.40 Questions and answers 13.00 Break part 2 14.00 R. Applegate USA Quality of vision evaluation 14.20 C. Roberts USA Biomechanics of the cornea 14.40 J.L. Güell SPAIN Refractive reoperations and enhancements 15.00 J.L. Alió SPAIN Customised ablational procedures 15.15 Break 15.35 M.C. Knorz GERMANY Non-optical complications of lAsIK and corneal surgery 16.00 V. Katsanevaki GREECE Optical complications of refractive surgery 16.15 R. Nuijts THE NETHERLANDS Complications of phakic IOls 16.35 Questions and answers 17.30 End of Course 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 10.00 – 11.30 new concepts of accommodative iOLs Chairpersons: P. Sourdille FRANCE, M. Tetz GERMANY 11.30 – 13.00 eSCrS/arVO Symposium: the impact of refractive surgery on corneal structure Chairperson: S. Kinoshita jAPAN 14.00 – 15.30 Surgical control of astigmatism Chairpersons: J.L. Alio SPAIN, T. Olsen DENMARK 15.30 – 17.30 perfect optics: Ocular light scattering Chairpersons: D. Spalton UK, M.J. Tassignon BELGIUM OtHer prOGramme HiGHLiGHtS Saturday 12 September 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 – 16.00 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 XXVII Congress of the ESCRS 12 – 16 September 2009 12 – 16 September

BARCELONA 2009 XXVII Congress of the ESCRS 12 – 16 September 2009 Saturday 12th September 13.00 – 14.00 The Femtolaser in Corneal Surgery and LASIK Sponsored by 13.00 – 14.00 Symposium Sponsored by 13.00 – 14.00 Meeting Patient Expectations Sponsored by 13.00 – 14.00 Symposium Sponsored by Appasamy Associates 13.00 – 14.00 Quality & Quantity of Vision: Optimising Outcomes with the Crystalens HDtm Sponsored by Sunday 13th September 13.00 – 14.00 Novel Approaches to Managing Patient Refractive Errors Sponsored by 13.00 – 14.00 Symposium Sponsored by 13.00 – 14.00 Antibiotic Prophylaxis in Cataract Surgery: Revision and Prospects Sponsored by 13.00 – 14.00 Experience with the HOYA AF-1 Platform Sponsored by 13.00 – 14.00 Rayner Satellite Meeting Sponsored by 13.00 – 14.00 Leading Technology in Refractive Surgery Sponsored by Lunchtime Symposia (lunchbox included) EUROTIMES ESCRS ™ SATELLITE EDUCATION PROGRAMME

Monday 14th September 13.00 – 14.00 Symposium Sponsored by 13.00 – 14.00 Symposium Sponsored by 13.00 – 14.00 Symposium Sponsored by 13.00 – 14.00 Symposium Sponsored by 13.00 – 14.00 Rayner Satellite Meeting Sponsored by Tuesday 15th September 13.00 – 14.00 Symposium Sponsored by Saturday 12th September 18.15 Cataract and Refractive Live Surgery Sponsored by Monday 14th September 18.15 The 4th MICS Symposium: Real Cases and Future Trends Sponsored by BARCELONA 2009 Evening Symposia WCPOS Lunchtime Symposia (lunchbox included) Saturday 12th September 13.00 – 14.00 ROP in 2009: Regional Solutions for Preventable Childhood Blindness Sponsored by Sunday 13th September 13.00 – 14.00 Managing Ocular Surface Infection in Paediatrics Sponsored byEUROTIMES ESCRS ™ SATELLITE EDUCATION PROGRAMME

by Gary Finnegan in Brighton BILATERAL same-day surgery can be the best option for carefully selected patients having multifocal intraocular lenses (IOLs) inserted, according to Richard Packard MD. Dr Packard said there are clinical and cost advantages to performing both surgeries in one trip to theatre, and this may also help patients adjust to a new way of seeing the world through multifocal IOLs. Speaking at the UKISCRS Annual Meeting, he said he did not believe there was any greater risk associated with same-day surgery and patients often find it more convenient. “From the patient’s point of view, there is only one hospitalisation and there may be decreased costs. Many of my patients travel from overseas so it is much better for them. However, none of these benefits would be important if there were going to be serious risks.” Dr Packard added that same-day surgery makes more efficient use of the operating theatre – “you can do two eyes on one patient far quicker than you do two eyes on two patients” – but surgeons should still treat each eye as a separate operation. “They need to be done as two totally separate procedures. You have to change everything, including instruments, tubing, drapes, solutions, viscoelastics and batches.” Dr Packard has used the ReSTOR multifocal lens (Alcon) for pseudophakic presbyopia in 420 patients over a five-year period. He advised surgeons contemplating multifocal implantation in their patients to steer clear of those with macular disease, corneal disease and tear film deficiencies. He acknowledged that adjusting to multifocal IOLs can prove challenging for some patients so preoperative counselling is critical in managing expectations. “There are some patients out there who think that you will be able to perform a miracle making them into a 25-year-old film star with perfect vision,” he said. Low myopes with good unaided reading vision are also best avoided as the quality of patients’ reading may be diminished with a multifocal lens. “They should not have astigmatism of more than 0.75 D of cylinder because all of these things will degrade the image very considerably.” He suggested occupational night drivers were initially an issue but since the aspheric version of the ReSTOR lens arrived, no longer. However patients with previous refractive surgery can often present challenges to inexperienced ophthalmologists fitting multifocal IOLs. “Previous refractive patients can certainly be done – we are much better at doing the calculations now than in the past – but when you’re starting I don’t think they are the ones to go for.” Dr Packard said surgeons can expect to treat increasing numbers of patients who have had refractive surgery and must establish their refractive history as early as possible in order to adjust calculations accordingly. In practice, he said patients should be provided with detailed written information on the risks and benefits of multifocal lenses and should then complete a questionnaire about their visual needs, their lifestyle and their personality. This is essential in grasping whether the patient will be able to adjust to the visual changes they experience following surgery. “There are specific multifocal issues patients need to understand. There will be a new way of seeing the world. Patients who do best are those who analyse least what is happening to their vision; those who are very picky and notice every little change will take longest to adapt.” Dr Packard said distance vision generally returns quite quickly. Reading vision generally takes a few days but intermediate vision is often not as good after a multifocal lens is fitted. He added that patients should also expect that their reading vision is going to be worse in poor light. “You need to find patients who are going to be able to understand what you tell them about these lenses. This will be important in how they adapt to them after implantation.” Having bilateral same-day surgery can prove beneficial in helping to adjust to living with multifocal IOLs. He showed the vision enhancement between uniocular and binocular vision even at the three-week postoperative stage. “There is no question that patients get better vision quicker due to summation between the two eyes. Neuroadaptation is very important and if the patient can begin this process from day one, so much the better.” This view was echoed by Peter Szurman MD who said a capacity for perceptual learning could help predict which patients are good candidates for a multifocal IOL. Dr Szurman said neuroadaptation always occurs after refractive surgery and even when adjusting to new spectacles, but poses a particular challenge with multifocal IOLs. This is because the retina has to deal with two images simultaneously. “Getting used to this is a higher cortical learning process.” He said improving neuroadaptation can help to enhance patient satisfaction, and research shows that training in basic psychophysical tasks can improve visual function. “Using a computer-based training program, contrast sensitivity and pattern recognition can be strengthened,” he said. Dr Szurman suggested that as neurobiologists learn more about neuroadaptation it may become a criterion for selecting patients suitable for multifocal IOLs. “Considering neuroadaptation is especially important when deciding which patients can benefit fully from a multifocal IOL. Patients have to have this ability to neuroadapt over time.” peter.szurman@med.uni-tuebingen.de eyequack@vossnet.co.uk EuropEan SociEty of cataract & rEfractivE SurgEonS Richard Packard 26 Refractive LensSame-day surgery can help patients adjust to multifocal IOLs 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)

28 Light Adjustable Lens provides precise refractive outcomes for outstanding vision Refractive Lens Cheryl Guttman in Berlin COMMERCIAL experience with the Light Adjustable Lens (LAL, from Calhoun Vision) mirrors the positive results seen in clinical trials, according to speakers at the XXVI Congress of the ESCRS. Pablo Artal PhD, presented refractive, wavefront, and visual acuity outcomes achieved in the first 30 eyes implanted by Jose Maria Marin, MD, an investigator in a multicentre European study supervised by the European chief medical officer Jose L Güell MD evaluating the LAL. The results were excellent, and surpassed those achieved in a control group of 30 eyes implanted with a conventional spherical IOL. The studies are corroborated by similar success stories from a subsequent series of consecutive eyes operated on by Dr Marin and initial commercial use of the LAL at the Ruhr University Eye Hospital, Bochum, Germany and elsewhere, he noted. “The LAL has been designed to allow nearly perfect refractive outcomes and improved quality of vision after cataract surgery, and the accumulating results are encouraging,” said Dr Artal, professor of physics, and founder and director of the Optics Laboratory, University of Murcia, Spain. “IOLs with an aspheric optic have been an important advance in pseudophakic implant technology. However, any benefit of reducing spherical aberration is negligible if there is significant residual refractive error. The main target for optimising vision after cataract surgery needs to be to eliminate defocus and astigmatism errors. This can be achieved with the LAL.” The LAL has the appearance of a standard posterior chamber IOL, but it is constructed of a silicone polymer as well as a photosensitive silicone macromer. Upon irradiation with UV light, the macromer undergoes polymerisation; subsequently, in order to re-establish chemical equilibrium in the lens mass, unreacted macromer diffuses to the irradiated area leading to a predictable change in lens curvature and hence refractive power. Patients are implanted with the lens and after waiting two to three weeks for the cornea to heal, are evaluated to determine the need for adjustment of the refractive outcome. The customised irradiation is performed using a digital light delivery device. To date, residual hyperopia, myopia, and astigmatism have been treated, with a range of correction of about 2.0 D of spherical error and 2.0 D of astigmatism. The LAL refraction can be adjusted up to two times and then two lock-in procedures are performed to ensure the lens power is fixed and will remain stable. The adjustment and lock-in procedures are performed using the same device but the light intensity magnitude is about 20 times higher for the photo-locking treatments as compared with the adjustment procedures. “This is a safe procedure considering the level of energy delivered. Importantly, these lenses have a highly efficient UV blocker incorporated in the posterior surface of the lens that reduces the amount of UV light transmitted to the posterior segment of the eye to well below the safety limit established by ocular safety standards and prevents retinal damage,” Dr Artal said. Clinical outcomes The study comparing outcomes after LAL and conventional spherical IOL implantation included groups of consecutive patients operated on by Dr Marin, including the first 30 LAL recipients. In the LAL group, mean defocus at the first postoperative evaluation prior to adjustment was 1.00 D. After the light adjustment and lock-in procedures, defocus was 0.00 D and remained stable through three months of follow-up. “While the mean residual defocus was also close to 0.00 D in the standard IOL group, the standard deviation in the LAL group was only 0.6 D and lower than in the conventional IOL group,” noted Dr Artal. The more impressive benefit of the LAL was seen in analysis of the cylinder outcomes. Mean cylinder at initial evaluation after surgery was -1.25 D in the LAL group. It was reduced by about half after the adjustment and lock-in procedures (mean 0.6 D ± 0.45 D) and remained stable after three months of follow-up. In contrast, eyes implanted with the standard IOL were left with -1.5 D of residual cylinder on average with a standard deviation of about 1.25 D. Mean decimal UCVA was 0.60 for both the LAL group pre-adjustment and in the conventional IOL group at last follow-up, but improved to 0.96 ± 0.14 in the LAL group at the three-month visit. Wavefront testing confirmed that the optics of the LAL remained stable at one and three months after lock-in. Results have also been analysed from the next 23 consecutive patients implanted by Dr Marin, of whom 13 were seen at three months’ post-lock-in and 10 were evaluated after one week. Twenty (87 per cent) of the 23 patients showed measurable improvement in their distance UCVA with the overall cohort having an average gain of two lines (Snellen acuity). Post-adjustment/lock-in UCVA was 20/25 or better in 20 (87 per cent) of the 23 eyes. Of the three who had no gain in vision, two maintained their pre-adjustment UCVA of 0.9 while the remaining patient had a slight decrease that was attributed to the onset of some posterior capsule opacification. Commercial experience Commercial LAL use began in Germany in May 2008. The Ruhr University Eye Hospital, Bochum, became the first commercial site where the digital light delivery device for treating the LAL was installed. Four more installations have been completed and two are under way, all in Germany. France, Italy, Spain, and the UK are expecting their first systems, according to Mr Jan Bonel, vice-president of marketing for Calhoun Vision, who is based in Barcelona, Spain. “Patient satisfaction after LAL implantation exceeds that for any other lens technology I have worked with in the past 10 years, and the refractive outcomes are so outstanding that they seem too good to be true,” Dr Dick told EuroTimes. He has implanted and adjusted close to 100 eyes. Mean deviation from target refraction is 0.25 D with a maximum of 0.5 D. Particularly impressive is the fact that the outcomes are similarly good in very short eyes, he noted. “Despite tremendous efforts expended to improve IOL power predictions in short eyes, they have remained a challenge and routinely subject to a greater deviation from target refraction.” D Verne Sharma, president and chief executive officer of Calhoun Vision, told EuroTimes that the LAL technology has been rapidly adopted at all of the sites where the digital light delivery device installation has been completed. “The doctors and patients are extremely happy because the LAL provides the ability to precisely tailor the outcome and correct any kind of refractive surprise up to 2 D,” he said. The company is undertaking the commercial launch with a conservative approach, he stressed. “It is very much in our best interest and that of the surgeons to be sure that they and their staff are knowledgeable about this technology and are able to select and counsel patients properly. To this end, we are careful to share and emphasise everything we’ve learned throughout the substantial amount of research and development work and clinical studies completed prior to the commercial launch,” Mr Sharma said. vsharma@calhounvision.com jbonel@calhounvision.com burkhard.dick@kk-bochum.de pablo@um.es Burkhard DickPablo Artal Courtesy of Pablo Artal PhDCourtesy of D Verne Sharma Light Adjustable Lens (LAL)

By Cheryl Guttman in Berlin PRESBYOPIC LASIK using a new non-linear aspheric ablation profile that increases the depth-of-field of the eye allows micro- monovision to safely and effectively treat presbyopia in combination with myopia, hyperopia, and emmetropia, said Dan Reinstein MD. The treatment represents a form of “laser blended vision” that uses a specialised non-linear aspheric ablation profile incorporated into the refractive correction to increase depth-of-field for simultaneous correction of distance and near vision. The dominant eye is targeted for exactly plano (mainly corrected for distance but also intermediate vision). The non-dominant eye is targeted for slight myopia (mainly corrected for near but also intermediate vision) with an ideal target of -1.50 D, although this may be varied between -0.75 and -1.75 D depending on age, the degree of presbyopia and patient tolerance. At the XXVI Congress of the ESCRS, Prof Reinstein presented results from an analysis of 366 consecutively treated patients that showed excellent combined binocular distance and near vision with little to no compromises in quality of vision. Combined UCVA of 20/20 or better at distance and J5 at near (newsprint) was achieved by 98 per cent of myopes (up to -8.50 D), 95 per cent of hyperopes (up to +5.75 D), and 96 per cent of emmetropes. “Non-linear aspheric micro-monovision LASIK is an extremely versatile presbyopic procedure because it can be performed for patients with refractions ranging from +5.75 to -8.50 D. In contrast to conventional monovision, it is very well tolerated since very little anisometropia is required. Based on these features and the outcomes we’ve achieved, almost all presbyopes who come into our clinic who are candidates for laser vision correction are now receiving this treatment,” said Prof Reinstein, medical director, London Vision Clinic, London, UK. The series he reported included 136 myopes, 111 hyperopes, and 119 emmetropes (SE -0.50 to +0.75 D). LASIK was performed in all eyes using the Hansatome zero compression microkeratome (Bausch & Lomb) and the MEL 80 excimer laser with CRS-Master (Carl Zeiss Meditec). Results were analysed based on one-year data with 90 per cent follow-up. In monocular visual acuity testing with data pooled for all patients (+5.75 to -8.50 D), distance UCVA was 20/20 or better in 92 per cent of eyes treated for distance and 20/63 or better in 80 per cent of eyes treated for near. In binocular testing, at least 95 per cent of patients in each of the three subgroups achieved distance UCVA of 20/20 or better, and 100 per cent achieved 20/32 or better. “The monocular distance acuity outcomes were excellent in their own right, probably as a result of the minimisation of induced spherical aberration afforded by the non-linear aspheric profile. By the same token, as a result of increasing the depth-of-field of the eyes, the distance vision of the eyes treated for near (left slightly myopic) was better than anticipated for the degree of targeted myopia. Neural summation between eyes provided additive effects, shown by the fact that the uncorrected distance vision was better binocularly than the distance vision of the dominant (plano) eyes alone,” Prof Reinstein said. “Even with the addition of considerably blurrier distance vision in the near eye, distance UCVA showed a boost in binocular testing compared with the vision achieved in the distance eye alone. Interestingly, in an ongoing prospective study, we are now investigating stereoacuity in patients with and without correction before and after surgery. We have been surprised by our preliminary findings showing that while uncorrected near stereoacuity is slightly reduced, stereoacuity is still present despite the discrepancy between the near vision acuity of the two eyes,” he said. After surgery, UCVA was the same, better than, or no worse than one line less than the preoperative BSCVA in 94 per cent of eyes based on data pooled for all patients. “This is an important endpoint to consider because the satisfaction of refractive surgery patients is generally related to how well their postoperative vision compares to their preoperative vision with glasses,” Prof Reinstein said. Binocular near vision results were excellent in all subgroups with 81 per cent to 96 per cent of patients seeing J2 or better, 94 per cent to 99 per cent seeing J3 or better, and all achieving J5 or better near vision. Consistent with the distance vision outcomes, the procedure demonstrated excellent refractive accuracy. The safety profile was also favourable. No eye lost two or more lines of BSCVA, while rates of one line loss in the myopic, hyperopic, and emmetropic subgroups were eight per cent, 17 per cent, and 13 per cent, respectively. Contrast sensitivity was either unchanged from the preoperative level or significantly increased at some spatial frequencies. “This treatment results in a form of hyperpolarization of the cornea that does not reduce contrast sensitivity or produce more than one image in the same eye. Some of the effects are to increase negative 4th order spherical aberration, which conveniently counterbalances the age-related increase in positive spherical aberration of the crystalline lens. It essentially places an on-visual axis reduction of spherical aberration of the crystalline lens, and that may explain why it increases contrast sensitivity. It also accounts for the increase in depth-of-field, which distinguishes this procedure from multifocal ablations or IOLs that can lead to image quality loss and a decrease in contrast sensitivity,” Prof Reinstein said. Prof Reinstein explained that this procedure is also differentiated from other forms of presbyLASIK and multifocal IOLs because it does not result in multiple images within the same eye. Instead, it takes advantage of the innate binocular neuroadaptation system in which neuronal gates, when presented with two visual fields from fellow eyes, instantaneously select the better image or elements of each to obtain the most effective single percept. However, in contrast to traditional monovision, this “laser blended vision” procedure results in an overlapping blend zone of vision in the intermediate range where both eyes have similar visual acuity that can be fused by the brain. With the “laser blended vision” procedure there is no dissociation between the eyes and much less suppression by the brain is required. “The ablation profile increases depth- of-field so that the dominant eye sees best in the mid-to-far distance range and the slightly myopic non-dominant eye sees best from near to mid-distance. The overlapping blend zone of clear vision and lesser amount of anisometropia distinguish this micro-monovision approach from traditional monovision where the depth-of- field is small, a significant amount of myopia is needed in the non-dominant eye, and the patient ends up with a middle blur zone,” said Prof Reinstein. The differences also translate into a significant difference in tolerability. “According to reports in the published literature, between 45 per cent and 60 per cent of patients (at most) are able to tolerate traditional monovision because of the significant anisometropia. In contrast, as we reported in the Journal of Refractive Surgery, we found a tolerance rate of 97 per cent for the micro-monovision procedure in preoperative screening of a series of presbyopic hyperopes.” Looking ahead, Prof Reinstein said the ultimate goal is to refine the ablation profile to increase depth-of-field enough in both eyes so that each achieves clear vision at all distances. “The current ablation is based on non- linear aspheric profiles that while effective for increasing depth-of-field, do not provide clear vision at all distances from far to near. We are not sure that this is achievable without compromising visual quality. In the meantime, the level of satisfaction amongst our patients makes us feel like we are on the doorsteps of presbyopic patient nirvana,” he said. dzr@londonvisionclinic.com 29 New LASIK ablation profile increases depth-of-field, presbyopia options Refractive Laser Dan Reinstein Courtesy of Dan Reinstein MD

Safer Procedures. Faster Recovery. Higher Quality Outcomes. choose the science to perfect it. The human eye is already a work of art, 56% less surge1Low endothelial cell loss2Essentially zero spherical aberration3 Visit www.AMOcataract.com or call 1-877-AMO-4-LIFE. 1. Georgescu D, Kuo AF, Kinard KI, Olson RJ. A fl uidics comparison of Alcon Infi niti, Bausch & Lomb Stellaris, and Advanced Medical Optics Signature phacoemulsifi cation machines. Am J Ophthalmol. 2008;145(6):1014-1017. 2. Holzer MP, Tetz MR, Auffarth GU, Welt R, Völcker H. Effect of Healon5 and 4 other viscoelastic substances on intraocular pressure and endothelium after cataract surgery. J Cataract Refract Surg. 2001;27:213-218. 3. TECNIS® Foldable Intraocular Lens [package insert]. Advanced Medical Optics, Inc. TECNIS® foldable intraocular lenses are indicated for primary implantation for the visual correction of aphakia in adults in whom a cataractous lens has been removed by phacoemulsifi cation. The lenses are intended to be placed in the capsular bag. Rx only. For a complete listing of precautions, warnings, and adverse events, refer to the package insert. Healon® OVD is used in ophthalmic surgical procedures to maintain a deep anterior chamber that facilitates manipulation inside the eye with reduced trauma to the corneal endothelium and other ocular tissues. Warnings/Precautions/Contraindications: There are no known contraindications to the use of Healon® OVD when used as recommended. Please refer to package inserts for full prescribing information. Rx only. The AMO Logo 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. ©2009 Abbott Medical Optics, INC., Santa Ana, CA 92705 www.AbbottMedicalOptics.com 2009.02.02-CT827B &$7*$EERWWB:RUN2I$UWB&7%LQGG30

Safer Procedures. Faster Recovery. Higher Quality Outcomes. choose the science to perfect it. The human eye is already a work of art, 56% less surge1Low endothelial cell loss2Essentially zero spherical aberration3 Visit www.AMOcataract.com or call 1-877-AMO-4-LIFE. 1. Georgescu D, Kuo AF, Kinard KI, Olson RJ. A fl uidics comparison of Alcon Infi niti, Bausch & Lomb Stellaris, and Advanced Medical Optics Signature phacoemulsifi cation machines. Am J Ophthalmol. 2008;145(6):1014-1017. 2. Holzer MP, Tetz MR, Auffarth GU, Welt R, Völcker H. Effect of Healon5 and 4 other viscoelastic substances on intraocular pressure and endothelium after cataract surgery. J Cataract Refract Surg. 2001;27:213-218. 3. TECNIS® Foldable Intraocular Lens [package insert]. Advanced Medical Optics, Inc. TECNIS® foldable intraocular lenses are indicated for primary implantation for the visual correction of aphakia in adults in whom a cataractous lens has been removed by phacoemulsifi cation. The lenses are intended to be placed in the capsular bag. Rx only. For a complete listing of precautions, warnings, and adverse events, refer to the package insert. Healon® OVD is used in ophthalmic surgical procedures to maintain a deep anterior chamber that facilitates manipulation inside the eye with reduced trauma to the corneal endothelium and other ocular tissues. Warnings/Precautions/Contraindications: There are no known contraindications to the use of Healon® OVD when used as recommended. Please refer to package inserts for full prescribing information. Rx only. The AMO Logo 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. ©2009 Abbott Medical Optics, INC., Santa Ana, CA 92705 www.AbbottMedicalOptics.com 2009.02.02-CT827B &$7*$EERWWB:RUN2I$UWB&7%LQGG30

By Cheryl Guttman in Berlin INTRACOR, an intrastromal treatment using the Femtec femtosecond laser (20/10 Perfect Vision) is a promising approach for presbyopic correction in emmetropic and hyperopic eyes, according to data presented at the XXVI Congress of the ESCRS. The flap-free, intracorneal procedure was developed by Luis Ruiz MD, Bogotá, Colombia, in 2007. A femtosecond laser must be used for the intrastromal ablation, and the Femtec was chosen from among the commercially available devices because of its unique curved patient interface. This feature minimises biomechanical impact on the eye during docking process and enables precise positioning of the laser beam. At the Istanbul Surgery Hospital, Turkey, Sinan Göker MD began performing the intraCOR procedure to treat presbyopia in February 2008. At the ESCRS Congress he reported having treated 170 eyes of 98 patients so far. However, after excluding eyes that were post-LASIK, pseudophakic or had less than one month of follow-up, he presented results for 86 emmetropic or hyperopic eyes of 51 patients. Ophthalmologists at the University of Heidelberg in Germany are participating in a prospective study under way at four centres. Since the trial was launched at their site in July 2008, they had accumulated a series of 20 patients who per protocol received treatment in the nondominant eye only. The longest duration of available follow-up was one month and was completed by nine patients. At both centres, patients have benefited with improvements in reading vision while maintaining or even perhaps gaining uncorrected distance vision. “This is a very fast, non-invasive treatment for presbyopia with potential safety advantages relating to the absence of any flap or surface ablation, and unlike other presbyopia treatments, it does not disturb distance vision. However, these are early results. Further follow-up in more eyes is needed to determine the long-term stability and predictability, and we are also developing nomograms for treating presbyopia in myopic and astigmatic eyes,” said Dr Göker. Mike P Holzer MD, University of Heidelberg, echoed Dr Göker’s cautious optimism about the initial results and advantages of the intrastromal treatment. “This new procedure has high potential for correcting low refractive errors like presbyopia, but also low myopia, hyperopia and astigmatism, and perhaps it could be considered for enhancement in eyes with residual refractive errors after IOL or excimer laser surgery,” Dr Holzer said. “It is appealing because it is non-invasive with no incision or pocket creation, and it leaves Bowman’s membrane, Descemet’s membrane, and the epithelium intact. At least so far, we have seen no evidence that the treatment causes weakening of the cornea. However, further validation of its efficacy and safety are necessary and we await the mid- and long-term outcomes.” The treatment involves a customised photodisruption pattern that is based on keratometry, refraction, age and corneal thickness. A series of concentric rings are placed consecutively within the central cornea at a predefined distance from each other. At one week post-op, the rings are only faintly visible at slit-lamp exam. “Together with the near correction, the treatment gives a slight plus correction in distance, which is why we selected patients with slight hyperopia,” Dr Göker said. Preoperatively, the eyes in Dr Göker’s series had a mean SE of +0.75 D, mean sphere of +0.93 D, and mean cylinder of -0.3 D. Postoperatively, mean SE, sphere, and cylinder were -0.12 D, -0.03 D, and -0.27 D. The treatment had no effect on axis of astigmatism. Analyses of UCVA data showed significant improvements were achieved in both mean distance UCVA (from 0.64 to 0.80) and near UCVA (from J13.3 to J2.3). In addition, whereas patients needed an average near add of +2.6 D to read J1 preoperatively, the same level of near vision was achieved at three months with a mean add of only +0.92 D. “In the eyes we treated, near vision was excellent on the first day after surgery and then regressed a little, but it improved again and seemed to stabilise at two to three months,” Dr Göker said. Best-corrected visual acuity remained unchanged in 88 per cent of eyes, while at three months, one eye had lost two lines of BSCVA and three eyes lost one line. Two of the latter cases resolved with treatment for dry eye. Mean BSCVA was slightly but significantly reduced from 0.99 to 0.95. “There is a little drop in distance BSCVA at one day and one week after surgery, but it generally stabilises at the preoperative level after two to three months,” noted Dr Göker. Corneal imaging pre- and postoperatively using the rotating Scheimpflug camera device (Pentacam, Oculus) showed the intrastromal treatment caused no change in mean central corneal thickness, while there were statistically significant increases in values for K1 (43.1 to 43.69 D), K2 (43.7 to 44.5 D), anterior surface asphericity (0.26 to 0.38), and posterior surface asphericity (0.37 to 0.50). Eligibility requirements for the study Dr Holzer reported require patients to have a near add of at least +2.0 D. The 20 patients included in his analysis had a mean age of 56 years and preoperative mean SE, sphere and cylinder values of +0.62 D, +0.78 D, and -0.33 D, respectively. Near UCVA, measured with a Sloan chart, averaged 0.70 (Snellen 20/100) preoperatively, had improved to 0.4 at one day and one week, and showed a further gain to 0.3 (20/40) at one month. “We had several patients who had dramatic improvements in near vision, approaching 20/20 at one month. One eye lost one line from 0.12 preoperatively to 0.1, and we are investigating the possible cause,” Dr Holzer said. Safety was further examined by comparing monocular and binocular near UCVA to make sure the treatment did not compromise binocular vision. In no patient examined at one week after surgery was the binocular near UCVA lower than the monocular near UCVA in the treated eye. Mean distance UCVA was 0.11 preoperatively, 0.07 at one week, and 0.05 at one month. “The slight improvement suggested by the one month results may reflect the fact that only nine patients were seen at that visit. A review of individual patient data from the preoperative and one-week visit shows distance UCVA stayed the same in almost all patients whereas five patients had some loss of vision. This decrease might be related to some slight oedema that remains at one week, but we will continue to follow these patients,” noted Dr Holzer. The study is also evaluating wavefront changes, topography, pachymetry, endothelial cell counts, contrast sensitivity, and patient satisfaction. The intraCOR treatment is thought to improve near vision in emmetropic and hyperopic eyes by inducing a redistribution of biomechanical forces that leads to corneal reshaping and multifocality. “The mechanism of the procedure requires further investigation, but the working principle, based on findings so far, suggest it results in a multifocality of the cornea due to changes in intracorneal fibres that lead to a slight change of the anterior and posterior corneal surfaces,” Dr Holzer told EuroTimes. s.goker@superonline.com mike.holzer@med.uni-heidelberg.de 32 intraCOR – first day intraCOR – same day intraCOR Courtesy of Sinan Göker MD Intrastromal presbyopic treatment yields impressive early results Sinan GökerMike P Holzer Refractive Laser

Devon Schuyler in Atlanta BEVACIZUMAB (Avastin, Genentech) injected into the subconjunctiva is an effective treatment for neovascularisation in penetrating keratoplasty (PK), according to a preliminary study presented at the annual AAO meeting. Corneal vascularisation decreased by more than 90 per cent in the five eyes studied, and no reinjections were needed by 12 months after treatment. No ocular or systemic adverse events occurred. The researchers chose to inject the agent into the subconjunctiva because chronic topical administration has been linked to epithelial toxicity. “We also believe that there is not enough information on the safety of systemic absorption with long- term topical administration,” said study presenter Merce Morral MD of Instituto de Microcirugia Ocular (IMO) in Barcelona, Spain. Dr Morral said that the injections worked even better than the investigators anticipated. “When we started injecting Avastin, we injected in the limbal quadrant where the density of the neovascular vessels was highest,” she said. “Not only was there a local effect of the anti- angiogenic agent, there was also reduced neovas- cularisation throughout the eye.” The study included five eyes in five patients that were undergoing penetrating keratoplasty for severe herpetic keratitis with corneal neovascularisation. Four of the five eyes had neovascularisation in at least three quadrants. The patients received 2.5 mg/0.1 mL of subconjunctival bevacizumab at the end of the procedure. Density and extent of vascularisation were recorded before injection and at one, six, and 12 months. In an interview after the presentation, Dr Morral explained that neovascularisation was quantified by taking digital slit-lamp photographs and recording the number of quadrants affected and growth up to the central cornea of superficial and deep vessels. One patient was a 35-year-old woman who had undergone previous penetrating keratoplasty for herpetic keratitis. She had a corneal ulcer that did not heal despite several amniotic membrane transplants. When the surgeons finally achieved closure of the ulcer, the eye was affected by corneal opacification and corneal neovascularisation. Six months after performing penetrating keratoplasty and injecting bevacizumab, the new vessels had regressed significantly. This improvement remained stable at 12 months. The second patient had a geographic ulcer and neovascularisation in one quadrant. The geographic ulcer had already recurred, leaving severe corneal opacification and deep, severe neovascularisation. “One year penetrating keratoplasty and bevacizumab injection, best-spectacle corrected visual acuity was 20/60 and the cornea was clear,” Dr Morral told EuroTimes. There was no recurrence of neovessels or ocular surface problems. Two patients had severe herpes simplex kerato-uveitis. The first patient was experiencing active inflammation, so penetrating keratoplasty and bevacizumab injections were postponed until the inflammation had been inactive for one year. Six months after treatment, mild ocular surface problems remained. “This is why we usually do an amniotic membrane transplant,” said Dr Morral. Fortunately, the ocular surface problems were mild and could be controlled with lubrication alone. No recurrence of neovessels was observed. The second patient had severe herpes simplex kerato-uveitis received a clear corneal graft, and experienced a clear resolution of neovascularisation at six months after treatment. The final patient had perforation of a peripheral corneal ulcer. Because this was considered a high-risk case, the patient received an amniotic membrane transplant in addition to the penetrating keratoplasty and bevacizumab injection. Six months later, the neovessels had partially regressed. Dr Morral concluded that bevacizumab is effective as an adjunctive therapeutic strategy for one of the two main complications of PK in patients with herpetic kerato-uveitis: neovascularisation and neurotrophic problems. Although PK with subconjunctival bevacizumab produced promising results in this study, Dr Morral said prospective randomised studies are needed to assess the efficacy and safety of this new therapy. She also pointed out that neovessels may recur, which would necessitate reinjection of the bevacizumab. If reinjection were necessary, retreatment guidelines would need to be established. “The authors should be commended for reporting a promising role for this treatment to reduce the risk of rejection association with vascularisation in patients with neovascularisation. But I think we have to consider these results preliminary until a larger series with controls can be undertaken,” said James Drake Auran MD, who is a professor of clinical ophthalmology at Columbia University in New York City. He pointed out that the study design had several limitations, including the fact that it was a non-randomised, open-label trial with no controls. Dr Auran said he was intrigued by the fact that there were no recurrences over the course of a year, and was no need to retreat. “We would expect neovascularisation to recur, and retreatment is typically required in neovascular AMD,” he said. He offered two hypotheses for why neovascularisation did not recur. One possibility is that the reduction in neovascularisation may “have been due in part to a reduced angiogenic load after the penetrating keratoplasty that reduced the stimulus for VEGF production.” Another possibility is that the postoperative steroid regimen played a role. He pointed out that having a control group would help answer this question. “I think the authors were wise to choose the subconjunctival route for drug delivery,” he said, noting recent work presented at the Cornea Society meeting immediately prior to the AAO, in which subconjunctival bevacizumab prevented corneal rejection in a mouse model, whereas topical bevacizumab did not. merce.morral@gmail.com JDAeye@aol.com 34 Bevacizumab injection effective for neovascularisation in penetrating keratoplasty Cornea Update `2XWSXWHQHUJ\!P- `SRLQWDLPLQJEHDP `'HIRFXVV\VWHP `%XUVWPRGH `$WWUDFWLYHSULFH 46YKVEJ<$ * 4/$6 $5&/DVHU*PE+ %HVVHPHUVWUD‰H '1UQEHUJ *HUPDQ\ ª      LQIR#DUFODVHUGH ZZZDUFODVHUGH 7LPHVB<$*BLQGG

Cheryl Guttman in Berlin DEEP anterior lamellar keratoplasty (DALK) may be associated with less long- term endothelial cell loss compared with penetrating keratoplasty (PK), suggests a12-month follow-up in a multicentre, prospective, randomised study. At the XXVI Congress of the ESCRS, Rudy Nuijts MD, PhD and Yanny YY Cheng MD, reported results on behalf of the Dutch Lamellar Corneal Transplantation Surgery (DLCTS) study group’s ongoing trial comparing DALK and PK. There were 26 eyes in the DALK group and 22 eyes that underwent PK. DALK was performed using Anwar’s “big bubble” technique to expose Descemet’s membrane. “By transplanting only the anterior side of the cornea, DALK can improve the efficiency of use of donor material compared with PK, theoretically decreasing the discard rate of donor tissue and shortening the waiting time for a transplant procedure. In addition, because it preserves the recipient endothelium, DALK offers a known advantage of having a lower endothelial rejection rate compared with PK. However, there are some unanswered questions about the rate of wound healing and visual recovery after DALK relative to PK, and it remains unclear whether DALK reduces astigmatism and is less traumatic to the endothelium,” said Dr Nuijts, director of the cornea clinic, University Hospital Maastricht, The Netherlands. The difficulty in performing DALK was demonstrated by the fact that there was a 28 per cent Descemet’s membrane perforation rate in the randomised study. Nonetheless the comparable functional outcomes with DALK and PK at 12 months, an absence of endothelial rejections after DALK compared with a 19 per cent rate in the PK group, and the suggestion from the 12-month data that endothelial cell loss may have stabilised in the DALK eyes are encouraging, he said. The DLCTS randomised trial is under way at the University Hospital Maastricht and five other centres in The Netherlands. Preoperatively, the DALK and PK groups were comparable with respect to mean age (~44 years), diagnosis (keratoconus 50 per cent, herpes simplex virus ~30 per cent), logMAR BSCVA, refractive astigmatism, topographic cylinder, and contrast sensitivity. Results from quarterly follow-up visits showed that BSCVA recovered faster after PK. However, at 12 months, mean logMAR BSCVA was not significantly different in the DALK and PK groups, 0.34 vs. 0.22, respectively. Contrast sensitivity also improved in both groups from baseline and was not significantly different between the DALK and PK groups at 12 months. “Compared with non-deep anterior lamellar procedures, DALK can achieve a better visual outcome because there is better attachment of the donor graft to the recipient tissue in DALK. However, residual stromal tissue after DALK may cause folds and opacification in the deep stroma that may reduce quality of vision,” said Dr Nuijts. “Recent data show that if the thickness of the residual stromal bed is less than 20 microns, visual acuity achieved with DALK can be comparable to that associated with PK. This can be achieved using the big bubble technique, which succeeds in baring Descemet’s completely.” Preoperatively, mean topographic astigmatism was 7.65 D in the DALK group and 7.09 in the PK eyes. The mean astigmatism values at 12 months were not significantly different in the DALK and PK eyes, 3.28 vs. 4.10 D. Mean refractive cylinder in the DALK and PK groups was also similar at 12 months, 3.28 vs. 4.10 D. Both groups also achieved a mean myopic SE, which was approximately the same in the DALK and PK eyes, -1.88 vs. -1.30 D, respectively. Mean endothelial cell density (ECD) was 2704 cells/mm2 in the PK group and 2450 cells/mm2 in the DALK group. Rates at 12 months in the two study groups were 1974 and 1838 cells/mm2 respectively. However, inspection of a graph plotting ECD over time suggested ECD loss may have stabilised at 12 months in the DALK group. “Based on earlier studies, we may expect a further decrease in ECD with time in the PK eyes,” Dr Nuijts said. There were seven (28 per cent) perforations in 25 DALK eyes, and the procedure was converted to PK in four eyes. Among the 18 eyes without a perforation, one had a pseudo-anterior chamber. In addition, one eye in the DALK group developed a cataract. “Perforation of Descemet’s membrane during DALK has been reported to occur at a rate of 10 per cent to 50 per cent, depending on the surgeon and the original disease. We had several surgeons involved in this multicentre study and most of us were in the learning curve, which affects the perforation rate,” noted Dr Nuijts. Roger F Steinert, MD, who was a moderator for the session, commented on the results. “Corneal transplant surgeons have all been struggling with lamellar procedures in terms of the learning curve and the impact on visual acuity. It is exciting to have these compelling data collected in the setting of a prospective, randomised study that show use of Anwar’s big bubble approach for Descemet’s separation may have successfully taken us over the barrier to achieving good visual outcomes after lamellar transplants,” said Dr Steinert, professor and chairman, department of ophthalmology, University of California, Irvine. Dr Steinert’s colleague, Marjan Farid, MD, introduced the idea of performing femtosecond laser-assisted DALK with a zigzag incision and the “Big Bubble” technique. If the big bubble endothelial dissection is successful, then the patient derives the benefits of DALK with the alignment advantages of the zigzag incision. “However, even if Descemet’s membrane ruptures, we keep the endothelium on the donor button, convert the procedure to a full-thickness PK, and the patient still derives the healing and vision benefits of the zigzag incision,” Dr Steinert said. rudy.nuijts@mumc.nl steinert@uci.edu 35 DALK outcomes favourable at 12 months in randomised, prospective Dutch trial Cornea Update Rudy NuijtsRoger F Steinert

Howard Larkin in Berlin A 24-MONTH trial with a new entry to the prostaglandin analogue class shows similar efficacy to latanoprost, while the preservative- free preparation could reduce side effects, reported researchers at the XXVI Congress of the ESCRS. Topical prostaglandin analogues, such as Xalatan (latanoprost 0.005 per cent) and Lumigan (bimatoprost 0.003 per cent), are among the most effective medical treatments for glaucoma, significantly lowering intraocular pressure with once-a-day dosing while maintaining effectiveness over treatment periods that can last for years. However, these drugs also are plagued by high rates of side effects. These range from mild to severe and include everything from minor irritation and inflammation to dry eye, blurred vision and lid oedema to changes in eye colour and thickening of eyelashes, to conjunctival hyperaemia and macular oedema. In one 2003 study by Nordman et al, 62 per cent of patients experienced at least one side effect, while nearly one-fifth experienced four or more problems, noted Hannu Uusitalo MD, Tampere, Finland. Even when these side effects are relatively mild, they present problems, Dr Uusitalo said. The more severe the side effects, the lower patient quality of life – and less likely patients are to adhere to dosing regimens. Some side effects, particularly conjunctival inflammation, also raise the chances that filtration surgery will fail, Dr Uusitalo added. Tafluprost, a fluorinated prostaglandin analogue, showed early promise. Animal tests suggested not only that the compound was more potent than some existing drugs, and it might irritate the eye less. It was developed into a clinical product by Santen Pharmaceutical, which now markets it as Taflotan in Denmark, and Tapros in Japan, where the product was approved in 2008. Applications for approval are pending in 12 other European countries, and tafluprost has recently completed a 24-month Phase III clinical trial involving 49 centres in eight countries involving 533 patients, 402 of which completed the trial. The results of the trial, which was structured as a non-inferiority test of tafluprost 0.0015 per cent versus latanoprost 0.005 per cent, are very promising, said Dr Uusitalo, who is an investigator for Santen and competitors. Both treatments yielded a substantial IOP reduction that was sustained over the entire 24 months, with tafluprost reducing pressure an average of 7.1 mmHg and latanoprost 7.7 mmHG. The limit for non-inferiority was set at 1.50 mmHg at a 95 per cent confidence interval. According to one statistical test, the analysis of variance or ANOVA, the difference fell within the limit at 1.38. However, when subjected to the ANCOVA test, which adds a covariant to the variance analysis, the difference fell just outside the limit at 1.52. Thus, non-inferiority was shown with ANOVA but not quite with ANCOVA. Adverse event rates were also statistically similar with comparable distribution, severity and causality between the two test groups. Overall incidence was 48 per cent in the tafluprost group and 44 per cent in the latanoprost group. The study shows that both compounds are effective and have similar safety profiles, Dr Uusitalo said, adding, “Tafluprost can be considered a good alternative to latanoprost.” However, the real advantage for tafluprost is that it is available in a preservative-free preparation, Dr Uusitalo emphasised. “The adverse effects on the surface of the eye are related to the dose and to the toxicity of both the active agent and any adjunctive agent, such as the preservative. In the case of prostaglandins, the active agent is relatively un-toxic. In commercially available preparations, the toxicity is closely correlated with the content of preservatives.” Dr Uusitalo presented data showing that the incidence of ocular symptoms, including burning, itching, foreign body sensations and dry eye were significantly reduced when patients were switched from latanoprost with a preservative to tafluprost without a preservative. In addition, signs of ocular inflammation were reduced, including the numbers of HLA-DR-positive epithelial cells and MUC5AC-expressing goblet cells. “These results suggest that long-term therapy with preservative-free tafluprost may be better tolerated by patients,” Dr Uusitalo said. This may increase the chances for the success of subsequent glaucoma surgical treatment by reducing long-term inflammation, Dr Uusitalo concluded. He called for further study to confirm these results and conclusions. hannu.uusitalo@uta.fi 37 Tafluprost emerging as alternative medical treatment for glaucoma Glaucoma Update Hannu Uusitalo

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

The 17th Congress of the European Society of Ophthalmology (SOE) will be held in Amsterdam, the Netherlands, June 13-16, 2009. In a recent interview, Gabriel van Rij, MD, PhD, SOE president, spoke to EuroTimes about the mission of the SOE, how the organisation’s programmes, including the SOE Congress, are designed to fulfil these goals, and the challenges facing European ophthalmology. Dr van Rij is professor of ophthalmology, Erasmus Medical Center, Rotterdam, The Netherlands. ET: What are the origins of the SOE and how is the organisation enhancing the development of ophthalmology in Europe? Dr van Rij: SOE is actually an acronym for Societas Ophthalmologica Europæa, which is Latin and translates into English as Society of European Ophthalmology. The organisation was started in 1956 for the purpose of promoting ophthalmology in Europe and to stimulate cooperation among European ophthalmologists and between the many national ophthalmological societies and subspecialty societies. Stated another way, the SOE essentially serves as a central coordinating organisation within Europe to promote ophthalmology education and communication among physicians and researchers in our field. Currently, 37 national societies are represented within the SOE structure. When the SOE was first launched, Europe was essentially divided into two parts, the West and the East, and one of the basic goals of the organisation was to reach out to ophthalmologists in Eastern Europe. Europe has undergone significant changes since the time the SOE began, but major differences in medical instruction persist so that fostering education of ophthalmologists in Eastern Europe in order to improve patient care in these countries continues to be an important goal of the SOE. To that end, each year, the SOE awards 70 educational grants to ophthalmologists-in-training in Eastern European countries that allows these individuals to build their skills and knowledge by studying in leading ophthalmic teaching centres in Western Europe. Further information about this opportunity is available online at ww.soevision.org/grants/. Another important initiative of the SOE is the European Ophthalmology Leadership Development (EuLPD) Programme. This course is fashioned after the Leadership Development Programme of the American Academy of Ophthalmology and was developed recognising the importance of training a pool of dedicated individuals who will have the skills to become future leaders of European, national, and international ophthalmology societies. Currently, the third EuLPD Programme is under way. Looking to assure a bright future for ophthalmology in Europe, the SOE also recently introduced the SOE Lecturer programme that encourages young ophthalmologists by recognising their achievements and promise. In each country, the national ophthalmology society chooses a clinician under the age of 40 to deliver a lecture at the group’s annual congress. In addition to the honor of presenting this talk and receiving a diploma commemorating the event, the chosen speaker is awarded free registration to the next congress of the SOE. As part of its educational mission, the SOE also collaborates with the European Community University Professors of Ophthalmology (EUPO, www.eupo.eu) to sponsor an annual subspecialty course for ophthalmologists in training. During years when the SOE Congress is held, the course takes place during the meeting. In Amsterdam, the EUPO course is on cornea, conjunctiva, and refractive surgery and is being held on June 12 and 13. ET: You mentioned that collaboration with subspecialty societies is an important element in the mission of the SOE. Please discuss how the collaboration with the European Society of Cataract and Refractive Surgeons (ESCRS) will be evidenced at the meeting in Amsterdam. Dr van Rij: We have been fortunate to have Marie-José Tassignon, MD, PhD, who is a past president of the ESCRS, working on our scientific programme committee to develop sessions related to cataract and refractive surgery. In addition, the ESCRS is organising three major symposia that will take place during the SOE Congress. One of these sessions will focus on the management of astigmatism in cataract surgery and it is being moderated by Paul Rosen, MD, and Dr Tassignon. Oliver Findl, MD, and David Spalton, MD, will be leading a session that will review the role of the posterior capsule in modern cataract surgery, and Ioannis Pallikaris, MD, and Jose Guell, MD, are moderators for a symposium that will examine the issue of preventing corneal ectasia after corneal refractive surgery. ET: What do you hope will be the primary take-home message from the meeting? Dr van Rij: The SOE Congress aims to be one of the premier meetings for ophthalmology education, and we hope attendees will take home new knowledge that will assist them in patient care and their research activities. We are especially proud of the high caliber scientific programme featured at the SOE Congress. In addition to a number of informative symposia that are co-sponsored by various subspecialty and supranational societies, the meeting agenda includes free paper and rapid fire sessions, poster and video presentations, instructional courses, and outstanding key note lectures. Great thought and effort is put into identifying topics that are of current interest to ophthalmologists across Europe and in selecting speakers who are key opinion leaders in their respective fields. In fact, one of the distinguishing features of the SOE Congress is that the majority of programme presenters appear on an invited only basis. Consequently, our faculty truly represents an international who’s who of ophthalmology. The topics and speakers for the key note lectures provide a good illustration of the quality of our programme. On Saturday, Dr Tassignon will be speaking on refractive cataract surgery. The next day is dedicated to glaucoma and Norbert Pfeiffer, MD, will deliver a lecture entitled “Why do we get glaucoma?” Monday, the key note lecture is devoted to retinal disease and Philip Rosenfeld, MD, PhD, will be speaking on the continuing revolution in therapy and imaging for age-related macular degeneration. Orbital surgery is the topic for the final key note lecture, and Geoffrey Rose, MD, will be speaking on “Cracking the orbit, greater returns for less damage.” ET: What are the major challenges facing ophthalmologists in Europe in 2009? Dr van Rij: From the standpoint of practice economics, reimbursement is a key issue as services provided are increasing but without a commensurate increase in fees. However, there are also many clinical challenges. New treatments and technologies are rapidly emerging and ophthalmologists face the need to stay abreast of these developments and learn new skills, but they also have the responsibility to act judiciously on the desire to offer patients the potential benefits of the latest therapeutic advances. We must be careful that the safety and efficacy of new treatments are established through appropriately rigorous study before they are widely adopted into clinical practice. ET: How can people learn more about SOE and the Amsterdam meeting? Dr van Rij: The best source is our website at www.soevision.org. The official meeting website is www.soe2009.org. ET: Finally, what are the future challenges that SOE faces as an organisation? Dr van Rij: Looking ahead, the SOE aims to not only maintain the scope of our existing programmes but also to expand the offerings. As is the case for most organisations and particularly in the current economic climate, our hope is that we will have adequate financial resources available to us to support these plans. Our goal of providing high quality, relevant education is also becoming more complicated because of the fact that ophthalmology in Europe is changing so rapidly, and yet there are still dramatic differences in the specialty among the many countries comprising the continent. g.vanrij@erasmusmc.nl 39 SOE looks to assure a bright future for ophthalmology in Europe Ocular Update Gabriel van Rij n Video Competition Winners n ePosters n Medal Lectures

O verhead is the bane of medical practice. No matter how much money comes in, the more you spend running your office, the less is left over for providing patient care, investing in new equipment, or lodging to your bank account. In most practices, staff is the largest overhead expense. The cost of employing staff consumes as much as 25 per cent of total practice revenues. That’s not necessarily a bad thing. After all, you need staff to administer your practice and perform routine clinical tasks that increase your own productivity. Indeed, the most profitable practices often have higher-than- average overhead ratios because they hire more clinical assistants who can help with clinical work-up, clinical record-keeping, and other technical tasks so their doctors can see – and bill – more patients. The optimum staffing level for your practice will vary depending on many factors. These include the type of services you provide, local standards of care, and the condition of your patients. But whatever that level may be, it’s important to make sure your staff is performing efficiently to maximise practice productivity. So with all those variables, how can you tell if your staff is productive? Measure what they do and keep track of it over time, says Helen D Neese, a medical practice productivity expert with the consulting firm of PivotHealth, which is based in the American city of Nashville, Tennessee. Ms Neese has worked with dozens of medical groups in all specialties developing custom productivity measurement and management programmes that have significantly improved performance. Ms Neese observes that industry benchmarks for staff overhead and productivity are great for general reference – if they exist for practices of your type in your community. But it’s always best to develop your own internal performance benchmarks to reflect the unique needs of your situation. This does require some work. Typically, an office manager or efficiency consultant will need to spend time observing what your staff does and how much time they spend doing it. This information can then be used to monitor and manage staffing levels. Ms Neese recommends the following steps: 1. Choose a standard productivity measure. For ambulatory clinics and medical offices, Ms Neese suggests Hours Per Patient Visit, or HPPV, as the standard measure. It is simply the number of hours worked by your staff divided by the number of patient visits in a given period. It is usually a good measure because the patient visit is the usual unit of service in these environments. While the services needed for individual visits will vary, the totals typically even out over even short periods of time. HPPV values should be determined for each job category for both clinical and non-clinical staff for each department or location. That way you can monitor performance in aggregate or by employee type and location, or even by individual. 2. Make task lists for each practice job. Productivity comes down to how many things you need to do and how much time you need to do them. Therefore, measuring it first requires figuring out what every employee is supposed to be doing. Since your receptionist and your medical assistants spend their time doing very different things, each should have their own, customised task list. For the receptionist, it might include checking in patients, answering phones, filing insurance claims and retrieving and filing medical records. For medical assistants it might include taking patients’ complaints and histories, vital signs, and administering preliminary vision tests. It’s most important to capture activities that are done the most often. It’s also important to define tasks consistently. For example, if you include verifying patients’ insurance coverage in the check-in process rather than treating it as a separate task, it is important to do so consistently from person to person and department to department so you can generate comparable data. 3. Time each task. Once you have a list of tasks, time your employees as they do them. There will be variations. To ensure reliable data, this should be done over a period of about two weeks, Ms Neese says. 4. Determine your provisional staff productivity standard. Based on your time studies, tally all the time taken for each task for all your patients in the study period and divide by the number of patient visits. This will tell you how much staff time it takes on average to perform each visit, or your provisional HPPV standard. This allows you to project how much staff you need to take care of a given number of patients. This figure can be further broken down by employee type. For example, if your HPPV is .3 hours clerical time and .4 hours medical assistant time per patient visit, to serve 20 patients ideally you will need to schedule six hours of clerical time and eight hours of medical assistant time. This assumes, of course, that you can reach 100 per cent efficiency with your staff. In the real world, however, you’re more likely to top out at about 85 per cent due to unavoidable downtime between patients, increasing staff to handle peak patient times, etc. You should adjust your HPPV to compensate – in this case perhaps .35 for clerical and .47 for medical assistants. These become the benchmarks by which you measure your productivity. 5. Track productivity over time. Once you have a clearer idea of how many staff you need to perform the work you have, project how much you will need based on expected patient loads, and track how much you actually use. If you find your total HPPV trending upward over time, this could mean your staff is operating at less than peak efficiency. This could help you identify opportunities to make better use of staff time. One way to do this is to adjust your schedule or your staff members’ schedules to avoid excess downtime. If you are in a larger setting with more than one clinic, it may be possible to cross-train staff members and have them move from one area to another as patient demand and physician schedules require, Ms Neese says. Benchmarking staff efficiency is also a good way to review your procedures. As you observe your staff, you may think of more-efficient ways for them to do their work, Ms Neese notes. Re-designing your office processes can often lead to efficiency and quality improvements – and that’s a real productivity gain. 41 Feature Practice Management How productive is your staff? Timing tasks can establish productivity benchmarks that will help you use staff more efficientlyby Howard Larkin European Registry of Quality Outcomes for Cataract & Refractive SurgeryEUREQUO with the kind contribution of What is EUREQUO? EUREQUO is a European Quality Registry for visual outcomes of cataract and refractive surgery See www.eurequo.org for more information Join the network EUREQUO gives a unique opportunity to monitor and compare results Quality registries create a sufficient basis for studying rare diseases, treatments and complications Collecting data will support you to make an audit report The collection of your data will facilitate the analysis of surgical outcomes and the development of evidence- based European Quality Guidelines

Feature T he European Union’s highest court has removed a major hurdle facing ophthalmologist-run companies that want to open private clinics. In a landmark decision, the Luxembourg-based European Court of Justice ruled illegal an Austrian law that required a company-owned clinic to obtain an “authorisation of need” to open. In its decision, the court stated that the legal principles of freedom of establishment and fairness precluded Austria from enforcing the authorisation of need rule against company-owned outpatient clinics but not against partnerships of dentists or doctors who offered the very same services. Under the Austrian legislation, a company-owned outpatient clinic could only open its doors for business if it received prior administrative authorisation. That authorisation was dependent on the clinic proving there was a need for its services, given the existing level of care available to persons living in the particular area. Under Austrian law, provincial governments were responsible for issuing such authorisation. By contrast, if a group of dentists or doctors formed a legal partnership – not a company – Austrian law allowed them to practice wherever they wanted in Austria without any need for prior authorisation. The events leading to the Court of Justice’s decision arose when a German- based company known as Hartlauer Handelsgesellschaft wanted to open a private dental clinic in Vienna. To do so, the company applied to the government of the Province of Vienna for authorisation. In August of 2001, the provincial government rejected the application based on a report produced by an official medical expert. According to the report, there were already enough public and private non-profit-making health institutions and other contractual practitioners offering comparable services in the Vienna area. The report based the conclusions on the ratio of the number of inhabitants to the number of dental practitioners. Based on the expert’s findings, the provincial government concluded that the clinic would not substantially improve dental services for patients in Vienna. In 2006, Hartlauer applied for authorisation to the government of the Province of Upper Austria to open a private dental clinic in the city of Wels, in north central Austria. Again, the provincial government rejected the application based on a lack of need. Hartlauer appealed both refusals to the Austrian Administrative Court arguing, that the refusal violated the EU principle of Freedom of Establishment. That freedom – for individual EU citizens – is enshrined in Article 43 of the EU Treaty. The Treaty extends the same freedom to EU companies in Article 48. In February of 2007, the Austrian court asked the European Court of Justice to rule on whether the requirement for authorisation of need violated the Freedom of Establishment. Lawyers for the Austrian provincial government attempted to justify the authorisation requirement by arguing that such authorisation was “indispensable” for maintaining the clinical quality, financial stability, and social solidarity of the Austrian medical system. In particular, they argued that an uncontrolled expansion of services by new outpatient dental clinics could threaten the ability of established dentists in the local area to continue offering services on an economical basis. The lawyers also argued that the authorisation restrictions were necessary because the law of supply and demand did not govern the health sector. The lawyers argued that demand is induced by supply, so that an increase in supply does not produce a fall in prices or a division of the same volume of services among several providers of services, but an increase in the volume of supplies at constant prices. The court considered the arguments in detail, before rejecting them. “Planning which requires prior authorisation for setting up new providers of services may prove indispensable for filling in possible gaps in access to outpatient care and for avoiding the duplication of structures, so as to ensure medical care which is adapted to the needs of the population, covers the entire territory and takes account of geographically isolated or other wise disadvantaged regions,” the court observed. “From that point of view, it is permissible for a Member State to organise medical care in such a way that it gives priority to a system of benefits in kind, so that all patients have easy access, throughout national territory, to the services of contractual practitioners. In the present case, however, two series of considerations prevent the legislation in question from being accepted as appropriate for ensuring attainment of the above objectives.” Relying on previous court decisions, the Court of Justice ruled that national laws that restrict the freedom of establishment can only be justified where there is a genuine objective that is pursued “in a consistent and systematic manner”. The application of Austrian law, however, was far from consistent and systematic, the court noted. The court highlighted the contradiction in Austrian law that required prior authorisation for a company-owned clinic but did not require authorisation for a group practice regardless of its size. “The premises and equipment of group practices and those of outpatient dental clinics may have comparable features and that in many cases the patient will not notice any difference between them,” the court added. “Moreover, group practices generally offer the same medical services as outpatient dental clinics and are subject to the same market conditions. Similarly, group practices and outpatient dental clinics may have comparable numbers of practitioners. “Since those two categories of providers of services may have comparable features and a comparable number of practitioners and provide medical services of equivalent volume, they may therefore have a similar impact on the market in medical services, and are thus liable to affect in an equivalent manner the economic situation of contractual practitioners in certain geographical areas and, in consequence, the attainment of the planning objectives pursued by the competent authorities,” the court wrote. “That inconsistency also affects the attainment of the objective of preventing a risk of serious harm to the financial balance of the national social security system. Even supposing that the uncontrolled establishment of independent outpatient dental clinics may lead to a considerable increase in the volume of medical services at constant prices to be paid for by that system, the Austrian Government has not put forward anything capable of explaining why the establishment of those clinics but not of group practices could have such an effect.” The court added that dental clinics may also be more economical than several competing practitioners. “The provision of dental care in those independent outpatient clinics is liable to prove more rational, in view of the way they are organised, the fact of having several practitioners, and the use in common of medical installations and equipment, which enable them to reduce their operating costs. They will thus be able to provide medical services in conditions that are less costly than those, in particular, of independent practitioners who do not have such opportunities. The provision of care services by those institutions may have the consequence of more efficient use of the public funds allocated to the statutory health insurance system,” the court continued. “In those circumstances, it must be concluded that the national legislation at issue in the main proceedings does not pursue the stated objectives in a consistent and systematic manner, since it does not make the setting up of group practices subject to a system of prior authorisation, as is the case with new outpatient dental clinics,” the court added. “It follows from all the foregoing that the national legislation at issue in the main proceedings is not appropriate for ensuring attainment of the objectives of maintaining a balanced high-quality medical service open to all and preventing the risk of serious harm to the financial balance of the social security system.” For details of the Court of Justice decision, Hartlauer Handelsgesellschaft mbH-v- Wiener Landesregierung and Oberösterreichische Landesregierung, visit the court’s website at www.curia.europa.eu. 42 The lawyers also argued that the authorisation restrictions were necessary because the law of supply and demand did not govern the health sector “That inconsistency also affects the attainment of the objective of preventing a risk of serious harm to the financial balance of the national social security system” European Court of Justice EU Matters by Paul McGinn Private ophthalmic surgery clinics receive boost from European court Court of Justice rules that Austrian law that requires ‘authorisation of need’ for private outpatient clinics is illegal

43 I n a move that reflects exploding demand for advanced ophthalmic technology in emerging markets – and the growing importance of those markets to major equipment manufacturers – Carl Zeiss Meditec launched its new phacoemulsification system in India. The unveiling of the Visalis 100 – at the All India Ophthalmic Conference – marked the first time that Carl Zeiss Meditec chose a developing market to introduce a major innovation. “We recognised the importance of the newly industrialising countries for the medical technology market at an early stage; therefore, it was a logical step for us to introduce Visalis 100 as part of our surgical ophthalmology solution specially tailored to the needs of these markets,” said Dr Michael Kaschke, the company’s president and chief executive officer. Just how important emerging markets are becoming for Carl Zeiss Meditec is evident in the company’s financial statements. For fiscal year 2007/2008, which ended 30 September 2008, the firm’s strongest growth was in the “Asia/Pacific” region, where revenue increased by 16.6 per cent to €138.5m. That region accounted for 23.1 per cent of the company’s total revenue in 2007/2008, up from 20.9 per cent the previous year. This rapid growth continued into the first quarter of fiscal year 2008/2009, with “Asia/Pacific” revenues up 61.4 per cent from the previous year’s quarter. In that quarter, the region’s revenues accounted for 25.7 per cent of the company’s total revenues. Growth also was strong in the “Europe, Middle East, and Africa” region, with revenues up 14.7 per cent to €194.1m in 2007/2008. There, growth was particularly strong in Eastern Europe and Germany, Dr Kaschke noted. By contrast, revenues from the “Americas” region, still the firm’s biggest, were down 12.7 per cent to €212.8m in the last fiscal year. When adjusted for exchange rate fluctuations, the drop in revenues in the Americas was only 2.8 per cent. A strengthening dollar spurred sharp gains in the Americas in the first 2008/2009 quarter, pushing total company revenues up 27.0 per cent over the same quarter a year earlier. “The positive trend in the first quarter once again highlights the advantage Carl Zeiss Meditec has with its wide range and well balanced portfolio, as well as our company’s global orientation,” Dr Kaschke added. The Visalis 100 was designed specifically to tap into emerging markets by meeting their unique needs, Dr Kaschke said. It is also well suited to ophthalmologists anywhere who serve patients in multiple locations. Its advanced safety features and storage of settings as well as the support for microincision surgery also make it an ideal match for both skilled surgeons, and for less-experienced surgeons and those in training. Weighing 13kg and measuring just 200mm x 400mm x 400mm, Visalis offers phaco, anterior vitrectomy, and diathermy capabilities in a package that is small enough to fit into tight operating quarters, and is truly portable. Visalis’ robust design minimises service and maintenance, a must for use in remote locations. Its fluidic system is completely closed with no internal tubing requiring cleaning, reducing the risk of cross-contamination. At the same time, its adaptive power control automatically minimises phaco energy during surgery while a surge security system stabilises the anterior chamber for maximum patient safety and excellent vision outcomes. The stroke is measured and stabilised by a microprocessor, and an intuitive graphical user interface with large display, touch-driven control, and voice confirmation allows easy adjustments in surgery. With the addition of Visalis 100, Carl Zeiss now offers surgeons worldwide comprehensive cataract solutions, including diagnostic instruments, surgical microscopes, viscoelastics, disposables, intraocular lenses and systems for follow- up care. “Particularly in the current phase of the global economy we are placing increased emphasis on innovation that is sharply focused on customer requirements such as ease of use, safety, productivity improvement, total cost of ownership and above all of course a proven patient benefit,” Dr Kaschke said. Fulfilling the brand promise Adding a sophisticated, reliable, and affordable phaco system is just one more way Carl Zeiss delivers on its brand promise – providing patients and surgeons with superior technology, Dr Kaschke said. Indeed, the brand of the Germany-based company appears on many ophthalmic devices considered as the “gold standard” in their categories. The strength of these products is reflected in their continuing sales despite tight economic times. Take the new OPMI Lumera surgical microscopes. They contributed significantly to Carl Zeiss Meditec’s outstanding first-quarter growth. The reason: Unprecedented ability to visualise details such as the surface of the capsular bag during surgery thanks to the revolutionary application of red reflex technology. “The new microscope with the xenon illumination achieves an unparalleled level of contrast and detail recognition in the red reflex,” said Thomas Neuhann, MD, Munich, Germany. Demand is increasing for surgical microscopes worldwide, with Asia potentially outstripping other regions by orders of magnitude due to growing population and prosperity. Similarly, the Cirrus optical tomography system achieved “gold-standard” status with its 1,000 placement in July. The Cirrus HD-OCT is the first spectral domain technology instrument to offer high definition 3D maps of individual retinal layers to reveal pathology hidden within the retinal tissue. These advanced imaging and analysis capabilities enable physicians to more confidently diagnose patients with retinal disease and glaucoma and monitor treatment results. With the global growth in glaucoma and other retinal diseases, Dr Kaschke expects continued growth for this technology. Based on its recent analysis of the optical technologies market, Frost & Sullivan recognises Carl Zeiss Meditec with the 2009 North American Frost & Sullivan Market Leadership Award for its optical coherence tomography (OCT) technology for ophthalmic applications. The IOLMaster recently achieved an even more significant milestone – Carl Zeiss Meditec installed the 10,000th device in November at a practice in the US. This success is founded not only on the convenience of the device compared with immersion ultrasound but also on its greater accuracy due to the non-contact IOLMaster optical technology. These combined benefits increase accuracy for and eliminate deviations among users. Recently released Version 5 software only expands the applicability of this gold-standard of the optical biometry essential to accurate IOL calculation. “With this improved software, we even were able to measure patients with posterior subcapsular or darkly brunescent cataracts,” said Oliver Findl, MD, MBA, London, UK. “Optical biometry has become easier than ever.” With the acquisition of Ioltech in 2005 and Acri.Tec in 2007, Carl Zeiss Meditec also entered the intraocular lens market in a big way. Examples of the portfolio are OVDs and innovative lenses like the AT.LISA which is presenting the first generation of high-performance aspheric multifocal IOLs (MIOL) for True MICS. AT.LISA is the only multifocal True MICS IOL on the market with a proven pseudo- accommodation range of 5 D, which is the best precondition for the desired postoperative outcome – life with minimal or no need for glasses. With AT.LISA toric the company is offering the world’s unique first aspheric toric multifocal IOL for true microincision surgery. As there is also a high interest from US surgeons, the firm is reviewing to offer the lens there as well. The current global financial downturn will certainly also have some effects on medical technology providers. But fundamentally the growth prospects are excellent and so Dr Kaschke expects long-term growth supported by Carl Zeiss Meditec’s strong and constantly improving customer-oriented innovations. “Given the uncertain general economic conditions, it is difficult to make a reliable and concrete statement regarding the outlook for financial year 2008/2009. We will, however, continue to prove our innovative strength by expanding our portfolio with the launch of new products. At the same time, we will further concentrate our efforts on markets with short-term growth opportunities. Our objective remains to further improve our profitability, without neglecting important strategic investments,” concluded Dr Kaschke. k.noessig@meditec.zeiss.com Feature Outlook on Industry Carl Zeiss Meditec looks to emerging markets for growth with new phaco system Launched in India, Visalis 100 is designed to meet the needs of developing countries by Howard Larkin CZM Visalis 100 CZM Cirrus HD-OCT Courtesy of Carl Zeiss Meditec

Feature I n the developing world, corneal ulceration is a major cause of blindness. As with so many conditions that are associated with disproportionate morbidity in the developing world, timely recognition and prompt instigation of appropriate management could reduce the impact of the disease. The problem is ensuring that this early response occurs. Availability of information for practitioners in all specialties is the key. Bacterial, viral, helminthic, and fungal infections are serious problems still in the developed world. In the developing world, they loom even larger. The consequences of such infections tend to be more serious in the developing world as the lack of timely and appropriate treatments makes progression more likely. In the midst of global recession and concerns about global warming, the simpler issue of the absence of very affordable medication is often ignored. Nevertheless, it is responsible for much misery, suffering, and a vast drain on scarce resources. It also affects children and young people, blighting lives and dashing hopes at an early age. Often, ophthalmic practice seems most concerned with high technology interventions. Of all medical specialties, it seems to be the one which is keenest to be at frontline of combining technical innovation with clinical practice. This is, of course, as it should be. It is also important that we all remember the fundamental ethical principle of equity, and the simple duty to alleviate and prevent suffering as much as we can. The tragic reality of our world today is that resources are distributed inequitably both within countries and internationally. As a profession, doctors have an ethical duty to be equitable in their practice, and while we can’t all leave our lives and duties and work for Médecins Sans Frontières, we can all consider a global perspective on justice. This book comes highly praised in its forewords by Prof Hugh R Taylor of the University of Melbourne Department of Ophthalmology, and by Prof Peter R Laibson of the Wills Eye Hospital. Sharma and Vajpayee, in their own preface, write that other texts produced to address this clinical issue tend to be information-dense, to an extent beyond that required for the routine management of a case of infectious keratitis. Information overload is as much of a problem in clinical practice in the modern world as lack of information. One can become paralysed by an embarrassment of options. Therefore, they have produced this book focused on the practical approach to specific clinical management. It aims to be a concise, succinct guide to the issues involved. Generally, it succeeds in this aim. There are five broad sections, each subdivided into chapters. These follow a familiar pattern. The first section is on applied basic sciences, in this case anatomy and physiology, pathogenesis of corneal ulcer, microbiology, and pharmacology. The section is on the work up of corneal ulcer. The third section focuses on the actual types of microbial keratitis – bacterial, fungal, viral, and protozoal. Specific clinical presentations follow in the fourth section. The fifth section concludes with surgical management. This is a familiar basic outline from most books of this type, moving from theoretical knowledge, to diagnosis, and to practice. Rather than the multi-author format of other books in this series, Sharma and Vajpayee contribute chapters themselves. This gives the book a unity of style and approach. Each chapter is well and unobtrusively referenced. There are copious colour illustrations and above all photographic images, each demonstrating important aspects of clinical management. Tables summarise key information throughout. The book is too large to serve as a vade mecum or to be carried into theatre very readily. It is really rather too bulky for everyday use, and as it is relatively slim in terms of pages; perhaps the dimensions of the book would have been better adjusted to produce a fatter but smaller volume. Nevertheless, the chapters are succinct and pragmatic and the overall approach is impressively focused on clinical concerns. The authors give a systematic approach to diagnosis and management of corneal ulcers. This takes the reader through the process from relatively simple presentations to much more complicated ones. This approach also gives the authors flexibility in the detail of their discussion. The surgeries are illustrated using a DVD that accompanies the book. This feature would have been a novelty only a few years ago but is now par for the course. Clearly, the authors have set themselves a major task, and they have produced a volume which addresses the issues. Many of the books which have been reviewed in this column have been from these publishers – Jaypee Brothers of New Delhi. They are beginning to produce a fine range of volumes on all aspects of ophthalmic surgery, which is becoming an excellent reference library. These books are well produced and designed and, again, provide evidence for the quality of Indian publishing in general. 44 In Your Good Books Response for corneal ulceration – where clinical management often meets resource limitsby Seamus Sweeney Corneal ulcers: Diagnosis and management Namrata Sharma, Rasik B Vajpayee Jaypee Brothers, New Delhi

45 Post-cataract endophthalmitis: can we do better? Though mercifully rare, endophthalmitis may be considered the most serious complication of intraocular surgery. Since cataract surgery is the most frequently performed surgical procedure worldwide, prevention of post-cataract- surgery endophthalmitis is an important goal of ophthalmic research. The April 2009 issue of the JCRS includes several important new articles on endophthalmitis risk reduction. T Kohnen, JCRS, “Post-cataract endophthalmitis: Can we do better?” April 2009, Volume 35, Issue 4, p. 609. Cost-effective sterilisation R Ravindran and colleagues report good results with a cost-effective sterilisation protocol in a high-volume eye hospital in southern India. They reviewed outcomes of more than 42,000 consecutive cases of cataract surgery using standardised sterilisation and prophylaxis protocols. Looking for cases occurring within three months of surgery, they found 38 cases of presumed postoperative endophthalmitis, an incidence of 0.09 per cent. Most, 35 of the 38 cases, were in the manual large- and small- incision extracapsular cataract extraction group. This was statistically significant when compared to the rate in the phacoemulsification group (P = .016). There was no statistical difference in the endophthalmitis rates between private patients and charity patients. The study involved a streamlined infection prophylaxis protocol that included the use of high-speed short-cycle steam sterilisation and continuous reuse of I/A tubing and irrigating solutions. The observed endophthalmitis rate in this study is comparable to that seen in US and European studies. The modified protocol enables the hospital to perform high-volume, efficient, and cost-effective cataract surgery. RD Ravindran et al., JCRS, “Incidence of post- cataract endophthalmitis at Aravind Eye Hospital: Outcomes of more than 42,000 consecutive cases using standardized sterilization and prophylaxis protocols”, April 2009, Volume 35, Issue 4, pp 629–636. Role for intracameral cefazolin? The landmark ESCRS endophthalmitis study provided support for using intracameral antibiotic agents (cefuroxime) in endophthalmitis prophylaxis. In a new study involving more than 50,000 phaco procedures, Spanish researchers report similar results with intracameral cefazolin injection. They compared the cumulative incidence of postoperative endophthalmitis before and after the addition of intracameral cefazolin during a six-year period. Introducing intracameral cefazolin reduced the incidence of endophthalmitis almost 10-fold (0.422 to 0.0.47). If only microbiologically proven cases were considered, the rate was also reduced 10-fold (0.388 to 0.032). Cefazolin fulfils international recommendations on antimicrobial prophylaxis for surgical site infections and is easier to obtain in developing countries, the researchers note. M Garat et al., JCRS, “Prophylactic intracameral cefazolin after cataract surgery: Endophthalmitis risk reduction and safety results in a 6-year study”, April 2009, Volume 35, Issue 4, pp 637-642. Clear cornea incisions a risk? Debate continues on the potential association between clear cornea incisions and endophthalmitis. H Al-Mezaine and colleagues compared endophthalmitis rates in 30,000 procedures, noting an overall endophthalmitis incidence of 0.068 per cent. They observed that clear corneal phacoemulsification carried a 1.73-times increased risk for endophthalmitis compared with ECCE. They caution that this result should be interpreted with care as cataract surgery moves toward a microincision procedure with incisions of 2.0mm and smaller. Such small incisions were not investigated in the current study. H S. Al-Mezaine et al, JCRS, “Acute-onset nosocomial endophthalmitis after cataract surgery: Incidence, clinical features, causative organisms, and visual outcomes,” April 2009, Volume 35, Issue 4, pp 643-649. Ophthalmologists called to battle against diabetes Ophthalmologists have an important role to play in the battle against diabetes, obesity and related metabolic diseases. The March issues of the Archives of Ophthalmology, the Archives of Neurology, along with the April issues of the Archives of Paediatrics & Adolescent Medicine, Archives of Dermatology and the Archives of Surgery, all focus on the need to include ophthalmologists on the team. Two editorials in the Archives of Ophthalmology emphasise the urgency of the situation, noting that the prevalence of diabetes has doubled in the past decade, with a resulting increase in diabetes-related eye disease. The number of cases of diabetic retinopathy is expected to triple by the year 2050, and significant increases in glaucoma and cataract are also a foregone conclusion. To effectively treat these conditions, ophthalmologists must go beyond surgically treating late-stage eye disease and work with other clinicians to help patients control their diabetes before eye complications worsen, the editorial notes. They note that ophthalmologists have a unique opportunity to influence patient behaviour because vision loss is one of the most feared complications of diabetes. Helping patients make the connection between their eye disease and the ABCs of diabetes (A1C, blood pressure and cholesterol) can motivate them to improve their health. A second editorial supports this point, citing the Epidemiology of Diabetes Interventions and Complications (EDIC) study, which confirmed the long-term benefits of initial tight glycaemic control. T Gardner, Arch Ophthalmology, “Diabetes and Obesity, A Challenge for Every Ophthalmologist”, 2009;127(3):328-329. R Frank, Arch Ophthalmology, “Editorial: Recent Study Results Validate Long-Term Value of Blood Glucose Control”, 2009;127[3]:330-331. No benefit with triamcinolone? The steroid triamcinolone does not appear to offer a long-term benefit in the treatment of diabetic macular oedema, and increases the rate of cataracts, a new study suggests. Investigators for the Diabetic Retinopathy Clinical Research Network report the three- year outcomes of a clinical trial in which 306 eyes of patients with diabetic macular oedema were randomly assigned to receive either photocoagulation, 1.0mg of intravitreal triamcinolone or 4.0mg of intravitreal triamcinolone. Three-year results showed no long-term benefit of intravitreal triamcinolone relative to focal/grid photocoagulation. Visual acuity outcomes slightly favoured the laser group over either of the two triamcinolone groups. Moreover, a majority of eyes receiving the higher dose of triamcinolone require cataract surgery, the researchers note. M Ip, Arch Ophthalmology, ‘Three-Year Follow- up of a Randomized Trial Comparing Focal/Grid Photocoagulation and Intravitreal Triamcinolone for Diabetic Macular Oedema”, 2009;127[3]:245- 451. Hang up on MRSE Your mobile phone may be transporting antibiotic-resistant bacteria, a new study suggests. Turkish researchers swabbed the dominant hand and the mobile phones of 200 doctors, nurses, and other healthcare staff working in intensive care units and operating rooms. They found that 95 per cent of telephones were contaminated, often with more than one type of microbe, and often with antibiotic-resistant bacteria. In total, 94.5 per cent of phones demonstrated evidence of bacterial contamination with different types of bacteria. The Gram negative strains were isolated from mobile phones of 31.3 per cent and the ceftazidime resistant strains from the hands were 39.5 per cent. S. aureus strains isolated from mobile phones of 52 per cent and those strains isolated from hands of 37.7 per cent were methicillin resistant. Distributions of the isolated microorganisms from mobile phones were similar to hands isolates. Some mobile phones were contaminated with nosocomial important pathogens. Interviewers also discovered that 90 per cent of the study participants admitted they never cleaned their mobile phones. The investigators recommend routine decontamination of mobile phones with alcohol-containing disinfectants. F Ulger et al., Annals of Clinical Microbiology and Antimicrobials, “Are we aware how contaminated our mobile phones with nosocomial pathogens?” 2009, 8:7 (6 March 2009) JCRS Highlightsby Thomas Kohnen Journal of Cataract and Refractive Surgery jointly published by the ESCRS and ASCRSJCRS Highlights by Sean Henahan Vision science highlights from the world’s leading journals of medicine and scienceJournal Watch Journal Watch

Industry News 46 Recent developments in the vision care industryIndustry News Industry consolidation continues The trend of industry consolidation continues apace. Cash rich companies are taking advantage of the current economic turmoil to acquire other companies that can increase their research pipelines, revenue streams, or both. Swiss giant Roche made a deal with biotech pioneer Genentech, acquiring the stock it did not already own for $46.8bn. Responding to concerns that the conservative Swiss company would spoil the creative spirit of the California-based Genentech, Roche agreed to let the early-stage drug research unit continue as an independent group within the larger company. Genentech is best known in the ophthalmology world as the maker of anti-VEGF agents bevacizumab (Avastin) and ranibizumab (Lucentis) used to treat wet AMD and other retinal diseases. Another huge consolidation occurred when Merck agreed to buy Schering-Plough for $32.6bn. Merck products include leading glaucoma medications such as Timoptic, Trusopt, and Cosopt. Merck is also collaborating with SurModics on an intravitreal implant offering sustained-release delivery of a drug to treat retinal diseases. Rumours are also circulating that Allergan may be a takeover target. The most likely buyer could be GlaxoSmithKline, although other suitors cannot be ruled out. Regulatory Updates FDA approval for AcrySof® IQ Toric Alcon received US FDA approval for its aspheric AcrySof® IQ Toric intraocular lens. The company notes that the new lens offers an enhanced aspheric optic that improves image quality and increases contrast sensitivity in cataract surgery patients with astigmatism. The thin lens design means the IOL is well suited for small incision cataract surgery. www.alcon.com Pneumatic trabeculoplasty in France Cytta Corp. announced that the reimbursement process for pneumatic trabeculoplasty (PNT) is to start in France. A six-month study to finalise government reimbursement approval for the PNT procedure is under way in two locations in France, the Hopital des Quinze-Vingts in Paris, and the Hopital Edouard Herriot in Lyon. Pneumatic trabeculoplasty is a two-minute, non-invasive, cost-effective treatment for glaucoma, owned by Ophthalmic International, Cytta Corp.’s wholly owned subsidiary. The treatment is approved in Europe. The approval process for France will allow any glaucoma patient in France to receive treatment at no cost. A similar plan for national reimbursement is currently under way in Italy. www.oi-pnt.com New uveitis treatment Sirion Therapeutics reported that the US FDA accepted a supplemental New Drug Application (sNDA) for Durezol (difluprednate ophthalmic emulsion) to treat endogenous anterior uveitis. The drug was approved last June for the treatment of postoperative inflammation and pain associated with ocular surgery. The sNDA includes data from several clinical studies demonstrating non- inferiority with Pred Forte one per cent (prednisolone acetate ophthalmic suspension, Allergan). www.siriontherapeutics.com Company News Bausch, Pfizer collaboration Bausch & Lomb reached an agreement with Pfizer to co-promote prescription ophthalmic pharmaceuticals. The five-year arrangement includes Pfizer’s latanoprost (Xalatan), and Bausch & Lomb’s loteprednol etabonate (Alrex, Lotemax) and Zylet, a combination of loteprednol and tobramycin. The deal also allows co-promotion of Bausch’s anti-infective eye drop, besifloxacin ophthalmic suspension, 0.6 per cent. Bausch also announced a development licensing agreement with Santen that allows them access to Santen’s hydrophobic acrylic polymers to use in development of IOLs. www.bausch.com www.pfizer.com www.santen.com Alcon places 75 Allegretto Lasers Alcon announced a five-year contract with high-volume LASIK provider LCA-Vision for 75 Allegretto Wave Eye-Q 400Hz excimer lasers, one for each of the company’s 75 LasikPlus® vision surgery centres. The Allegretto system combines proprietary wavefront-optimised PerfectPulse Technology®, precise laser control and unparalleled speed for the most advanced laser technology in LASIK surgery, the company says. www.alcon.com Clinical trials Tearlab study under way OccuLogix (dba TearLab Corporation) announced the start of an international clinical study designed to demonstrate the efficacy of the TearLab™ Osmolarity System. The company says the system, which measures the osmolarity of tears, is a practical tool for the diagnosis and assessment of severity of dry eye disease. The 10-site TearLab Osmolarity System Core Validation Study will enrol up to 500 subjects at sites in the US, Europe and Japan. Alcon is a sponsor of the study. www.occulogix.com DME Phase II study Belgian company ThromboGenics announced that patient enrolment is now complete for its Phase II trial of microplasmin intravitreal injection for the treatment of diabetic macular oedema. This trial, known as MIVI II DME, is a randomised, double masked, placebo injection controlled, dose ascending clinical trial that will follow 50 patients for one year. www.thrombogenics.com New intravitreal implant study Alimera Sciences reports that interim results from a Phase II study of an intravitreal insert (Iluvien) shows promise for the treatment of diabetic macular oedema. This 36-month, open-label, Phase II study is designed to assess systemic exposure of the corticosteroid, fluocinolone acetonide after administration of Iluvien in patients with diabetic macular oedema. The one-year interim data showed no adverse events related to intraocular pressure in low-dose (0.23 μg per day) patients, but 23.5 per cent of the high-dose (0.45μg per day) patients experienced IOP increases of 30 mmHg or greater during that period. Each Iluvien insert is designed to provide a sustained therapeutic effect, up to 36 months for the low dose and up to 24 months for the high dose. Iluvien is inserted into the eye with a 25-gauge needle. The phase II trial is being conducted concurrently with the Phase III FAME Study (Fluocinolone Acetonide in Diabetic Macular Edema). www.alimerasciences.com Episcleral implant study enters phase III Lux Biosciences reports that enrolment is complete for the LUCIDA Phase III trial. That study is evaluating LX201, a silicone matrix episcleral implant that provides a continuous release of cyclosporine A for up to one year. The trial enrolled 493 patients at elevated immune-mediated risk of rejection or graft loss subsequent to cornea transplantation. The device is implanted under the eyelid into the subconjunctival space. It has received Orphan Drug status in both the US and Europe, and Fast Track status in the US. www.luxbio.com New Products Brilliant Peel® – new disposable syringes Brilliant Peel®, a synthetic non-toxic dye used for selective, intraocular staining of the internal limiting membrane is now available in disposable syringes. Each pre-filled syringe contains 0.5ml, enough for one application. www.geuder.de

47 F or every percentage point that unemployment rises in the US, 1.1 million Americans lose health insurance coverage. With unemployment up more than three points since the recession began, this suggests about 50 million people now lack coverage. And, of course, vital health protection agencies, including the federal Food and Drug Administration and the Environmental Protection Agency, and myriad state regulatory bodies desperately need rejuvenation after years of budgetary and administrative neglect. With a $787bn stimulus package passed and another $634bn earmarked for health system reform in President Barack Obama’s 10-year budget plan, the new administration is on it. Change is under way in the US health system. “The Academy understands ‘change’ is more than a catchy campaign slogan, and healthcare is front-and-centre for action in 2009,” said Michael X Repka MD, secretary for federal affairs for the American Academy of Ophthalmology. “This is the biggest healthcare legislative year in more than a decade, and the Academy is committed to lead the drive for change that includes Medicare reform.” But while a lot of good already has been done, there’s still a huge chunk of bad to be addressed in the nation’s health infrastructure. And with the bulk of permanent reform yet to be determined by a Congress that will be heavily pressured by special interests, there will be some ugly fights before it’s done. The good: stimulus aids unemployed, prepares for reform The stimulus package provides nearly $87bn over two years to supplement state Medicaid programs, which are jointly funded by federal and state governments to provide coverage for low-income and disabled individuals. The package also includes nearly $25bn to subsidise extension of employer- sponsored health insurance for laid-off workers. Under current law, workers may keep insurance coverage offered by former employers for 18 months – provided they can come up with 102 per cent of the premium costs. However, the cost of such coverage, which averaged $4,704 for individuals and $12,680 for families in 2007, is unaffordable for most unemployed workers. The federal funds will pay 65 per cent of the cost for up to nine months, extending a needed lifeline to many struggling families. And in what Obama calls a down payment on health system reform, the package also offers $19bn to help hospitals and doctors buy electronic medical records. With US health costs highest in the world, improving efficiency is widely seen as necessary for successful reform. The Congressional Budget Office estimates that better information technology could eventually reduce national healthcare spending by $12bn annually through better quality and care coordination, and fewer medical errors and duplicative care. Other items seen as essential for reform include $10bn to the National Institutes of Health for research, $2bn for community health centres that serve low-income areas, $1.1bn to start an office of comparative effectiveness research, and $500m for educating primary care physicians. The bad: safety net and food safety systems still underfunded While an $87bn bump in Medicaid is most welcome, it won’t make more than a medium-size dent in state budget deficits. Falling tax revenues leave 42 of the 50 states facing a combined budget deficit of close to $100bn, or about 15 per cent, in this fiscal year, according to the Center on Budget and Policy Priorities. Deficits could top $145bn next year. In many states Medicaid is the biggest budget item. Several states have cut payments to hospitals and physicians, even though many providers already limit the number of Medicaid patients they treat because payments are well below costs. Safety of the nation’s food and drug supplies also remains in question. The saga of the Peanut Corporation of America is a recent and egregious example of the failure of both federal and state regulators to prevent a nationwide salmonella outbreak. Some estimate it has sickened more than 22,000 and killed nine, though the Centers for Disease Control and Prevention has confirmed only about 700 cases in 43 states. It turns out that not only did the FDA repeatedly fail to follow up on reports of salmonella in peanut products from a plant the firm operated in Georgia, but also Texas health officials never once inspected a plant that opened there four years ago until the recent disease outbreak was in full swing. The company is now in bankruptcy. Although the Obama administration has begun a comprehensive review of US food safety, the capacity of many agencies to monitor food and drugs has been greatly reduced in recent years as inflation eroded stagnant budgets. The ugly: special interests and reform As with any law an administration desires, the president proposes, but Congress disposes. With the collapse of the 1994 Clinton health reform still haunting the White House, Obama has forgone a detailed reform plan in favour of outlining broad principles and leaving it to Congressional leaders to work out the details. And work it out they will. Democratic committee chairs are jockeying for position with competing proposals. Some want to require everyone to buy insurance, some do not. Some want to tax employer-sponsored benefits above a set level, others do not. Some want a public plan that anyone can join to compete with private health insurers, and some insist this will destroy the health insurance market. Then there’s industry. Physicians, hospitals, single-payer advocates, insurance companies, pharmaceutical companies, unions, and major employers are all politely agreeing to support needed reforms. But when push comes to shove their lobbyists will be out in force to protect their interests. In particular, ophthalmologists and other physicians see moves toward “value-based purchasing” – which differentiates among physicians based on quality and efficiency – as a potential threat. But doctors also see reform as an opportunity to end a Medicare system that automatically lowers payments each year unless Congress intervenes. Insurers see an upside to requiring everyone to buy coverage. But they fear competing with a government-sponsored plan that might use the power to set rates to undercut them. And pharmaceutical companies will fight hard to prevent government from negotiating drug prices in bulk. The sausage grinder of public policy is kicking into high gear. Let’s hope what comes out isn’t too ugly. The saga of the Peanut Corporation of America is a recent and egregious example of the failure of both federal and state regulators to prevent a nationwide salmonella outbreak Feature Letter from America Healthcare in recession: The good, the bad, and the ugly Stimulus bill launched some needed reforms, but permanent solutions are a long way off by Howard Larkin

May 2009 9-13 PARIS, FRANCE 115th SFO Congress Email: sfo@sfo.asso.fr Web: www.sfo.asso.fr 14-17 NICE, FRANCE 9th EURETINA Congress Tel: +353 1 209 1100 / Fax: +353 1 209 1112 Email: euretina@euretina.org Web: www.euretina.org 16-19 BALI, INDONESIA 24th Congress of the Asia-Pacific Academy of Ophthalmology Tel: +(62-21) 319 07282 / Fax: +(62-21) 392 7516 Web: www.apao2009bali.org 19-21 BIRMINGHAM, Uk The Royal College of Ophthalmologists Annual Congress Email: events@rcophth.ac.uk Web: www.rcophth.ac.uk/scientific 20-23 ROME, ITALy 7th SOI International Congress Web: www.sedesoi.com 23 BELGRADE, SERBIA International Memorial Symposium Tel: + 381 11 243 7503 / Fax: + 381 11 245 5759 Email: info@milosklinika.com Web: www.milosklinika.com 30- PRAGUE, CzECH REPUBLIC 2 June The 10th Congress of International Ocular Inflammation Society (IOIS) Tel: +420 284 001 444 / Fax: +420 284 001 448 Email: ioisprague2009@guarant.cz www.ioisprague2009.com June 2009 12 BORDEAUx, FRANCE 3rd International Conference on Femtosecond Lasers in Ophthalmology Tel: +1 484 581 1835 / Fax: +1 484 450 2682 Email: aogrady@bmctoday.com Web: www.icflo.org 13-16 AMSTERDAM, NETHERLANDS 17th Congress of European Society of Ophthalmology (SOE) Web: www.soe2009.org 18-21 NüRNBERG, GERMANy DOC Congress 2009 Web: www.doc-nuernberg.de 20 SIRMIONE (BRESCIA), ITALy World Vision Surgery Symposium 2009, 2nd Edition Tel: +39 334 576 5357/ Fax: +39 030 24 28 248 Email: segreteriascientifica@sicr.it Web: www.sicr.it 26-27 BATUMI, GEORGIA VII Annual Meeting of Black Sea Ophthalmological Society (BSOS) Web: eyeclinic.ge/index.php?lng=ge_&page=bsos July 2009 8-11 BOSTON, MA, USA WORLD GLAUCOMA CONGRESS 2009 and International Glaucoma Symposium Web: www.worldglaucoma.org September 2009 BARCELONA, SPAIN 12-16 xxVII Congress of the ESCRS Tel: +353 1 209 1100 / Fax: +353 1 209 1112 Email: escrs@escrs.org Web: www.escrs.org 12-13 World Congress of Paediatric Ophthalmology and Strabismus (during the xxVII Congress of the ESCRS) Tel: +353 1 209 1100 / Fax: +353 1 209 1112 wcpos@agenda-comm.ie Web: www.wcpos.org 12-16 ISTANBUL, TURkEy 22nd ECNP Congress Tel: +32 2 777 0188 / Fax: +32 2 779 5960 Email: ecnp2009@iceo.be 24-27 SEOUL, SOUTH kOREA 5th International Meeting on Advanced Cataract & Refractive Surgery Tel: +32 2 777 0188 / Fax: +32 2 779 5960 Email: ecnp2009@iceo.be 30- PORTOROž, SLOVENIA 3 Oct European Association for Vision and Eye Research 2009 Web: www.ever.be Email: ever@ever.be October 2009 8-9 LEEDS, Uk 33rd Annual Meeting of UkISCRS Web: www.ukiscrs.org.uk 9-11 DUBROVNIk, CROATIA 5th International Ophthalmologic School Email: info@cscrs.hr Web: www.cscrs.hr 24-27 SAN FRANCISCO, CA, USA American Academy of Ophthalmology Joint meeting with PAAO Tel: +1 415 447 0320 / Fax: +1 415 561 8576 Email: meetings@aao.org Web: www.aao.org/annual_meeting November 2009 12-14 MOSCOW, RUSSIA S. 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