November Eurotimes

VOLUME 14 ISSUE 11 NOVEMBER 2009 A Publication by the European Society of Cataract & Refractive Surgeons

1 “A destination is often not a place but a new way of seeing things,” said Disraeli, and no truer could it have been of Barcelona, September 12–13, 2009. Indeed Barcelona is a beautiful, Gaudiesque city, peppered with glorious culture, vivacious architecture, Catalonian beauties (of both genders, my wife reminds me) and of course that magnificent Sagrada Familia cathedral stretching to the heavens like an imploring hand. Something very special happened there on September 12 and 13; we all saw a new way of doing things. The inaugural World Congress of Paediatric Ophthalmology and Strabismus (WCPOS) was only a whimsical fancy two years ago but with the help of Paul Rosen, president of the ESCRS and the organising secretariat of the ESCRS, it became a living dream for David Granet and I. The ethos was clear – expertise does not reside in one part of the world – with this in mind we set about putting together an international and local organising committee with the dedication and enthusiasm we shared. The two keynote lecturers were outstanding with Jack Kanski discussing Juvenile Idiopathic Uveitis and Kenneth Wright discussing Innovations in Strabismus. To have two such icons as inaugural lecturers was awe inspiring and energising. The autograph sessions post lectures were more akin to those seen when rock legends meet their adoring fans. The aim of the meeting was to get people from around the world to share ideas. One classic example was the ‘Strabismus Techniques’ session: a discussion ensued between moderators and the audience about the regular use of an operating microscope for strabismus surgery. Over 50 per cent of the audience used the operating microscope which was enlightening for those of us who never have. There are many highlights that fleet across my mind about this meeting but the one fact that David Granet and I still can’t quite assimilate is the sheer number of attendees. 940 attendees from 90 different countries; of the 940 just over 200 were joint attendees with ESCRS and the rest just WCPOS attendees. This of course resulted in shortage of space because we had never imagined so many attendees would materialise. Many, many sessions had standing room only. Much of the success was due to the quality of the speakers and the sessions. All the speakers paid for their own registration and expenses; a real testament to the teamwork and spirit the paediatric ophthalmology and strabismus world believes in. The meeting closed with the ‘My World, My Way ‘session: a showcase for the less heard individuals from far flung places like Bhutan, Afghanistan/Pakistan, Romania, Brazil, Oman and Nigeria – a truly global village. So what next? Certainly there will be WCPOS II in Milan September 8–9, 2012. The hope is that it will be bigger and better but the ethos will remain the same: “Expertise does not reside in one part of the World”. In order to facilitate this we have formed the World Society of Paediatric Ophthalmology and Strabismus (WSPOS). This organisation encourages and indeed relies on regional organisations and where regional organisations are not present, will encourage and help develop them. International collaboration and contribution usually only comes when there is local pride. We want to help develop that where it is lacking and collaborate with those regional organisations that already exist. Membership comes from membership of a regional organisation or directly if none exists. There are no joining fees. In the coming months we will be releasing podcasts of some of the meeting on the WSPOS website which is to be launched by Christmas 2009. We hope in years to come WCPOS Barcelona 2009 will be remembered as the birthplace of a new beginning, a new way of seeing things. Ken Nischal is a consultant ophthalmic surgeon at Great Ormond Street Hospital for Children and Moorfields Eye Hospital (Hon.) in London and is a co-director of WCPOS with David Granet kkn@btinternet.com Guest Editorial Ken K Nischal FRCOphth Noel Alpins australia Bekir Aslan turKEY Bill Aylward uK Peter Barry irElaND Roberto Bellucci italY Hiroko Bissen-Miyajima JaPaN John Chang CHiNa Joseph Colin FraNCE 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 Oliver Zeitz GErMaNY José GüellIoannis Pallikaris Clive PeckarPaul Rosen Emanuel Rosen Chairman ESCRS Publication Committee Medical Editors International Editorial Board Building on the success of first WCPOS meeting in Barcelona Editorial November Pictured from left to right: David Granet, Kenneth Wright, Jack Kanski and Ken K Nischal

2 12 Questions remain about who should perform YAG laser capsulotomy 13 Call for intracameral antibiotic preparation protocols to be audited 14 ORange device beneficial for enhancing LRI outcomes 15 Survey shows lens decentration a leading cause of lens explantation Cataract Update 6 Cover Story: New standards of practice for amblyopia therapy discussed 10 Underlying cause of blindness in children needs to be tackled universally Special Focus – Paediatric Ophthalmology 20 New device may advance diagnosis of dry eye disease 21 Gene-based approaches to regulating corneal wound healing Cornea Update 6 Special Focus> 12 Cataract> 20 Cornea> 28 Retina> Contents Refractive Lens 18 Delivering medication directly to the eye has benefits over injections More Contents

4 Contents 22 Neuroprotective treatments may yet be developed for glaucoma 23 Is IOP fluctuation predictive of glaucoma? Glaucoma Update 24 Promising new strategy for the treatment of neovascular AMD 25 Trial confirms safety and efficacy of ranibizumab treatment 28 New device for diabetic retinopathy detection Retina Update 29 European and US practice differences persist, annual survey shows 30 EUREQUO set for 2010 roll-out 31 Diabetes-related ocular disease on the increase in MEACO region Ocular Update 32 Eye on History 35 In Your Good Books 36 Practice Development 38 Outlook on Industry 40 John Henahan Prize 45 EU Matters Features 8 Newsmaker Interview 39 Industry News 41 JCRS Highlights 43 Journal Watch 47 Product Update 48 Calendar Regulars 32 Features>47 Regulars> 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 Included with this issue:

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Roibeard O’hEineachain in Barcelona AS THE scientific understanding of amblyopia advances and clinical evidence accumulates, new standards of practice are beginning to emerge. At the first World Congress of Paediatric Ophthalmology and Strabismus (WCPOS), held in conjunction with the XXVII Congress of the ESCRS, a symposium addressed the many controversies regarding the optimum treatment of amblyopia. Current evidence suggests that a gradual and measured approach will achieve excellent results, minimising unnecessary interventions in children with anisometropic and strabismic amblyopia, according to Jonathan Holmes BM, BCh, Mayo Clinic, Rochester Minnesota, and current chair of the PEDIG study group (Paediatric Eye Disease Investigator Group). He noted that PEDIG involves over 300 paediatric ophthalmologists and paediatric optometrists from private practices and academic institutions across North America. They conduct large randomised controlled trials and observational studies. Typically 50-80 investigators participate in each individual study, he said. One aim of the PEDIG group’s research is to evaluate the effectiveness of current practices under real world conditions, he continued. The studies involve the standardised assessment of visual outcomes using masked assessors. However, they do not involve monitoring of adherence to the prescribed regimens and therefore may more closely resemble the situations encountered in clinical practice. Refractive correction alone adequate for many Dr Holmes said that the PEDIG studies indicate that optical correction alone may be effective in many cases. The studies also indicate that in those unresponsive to optical correction the next reasonable step is to start patching the fellow eye two hours a day or use twice weekly atropine drops to the fellow eye. However, he stressed that if a plano lens is used in addition to atropine, careful monitoring of visual acuity of the fellow eye is necessary to avoid inducing reverse amblyopia. In one observational study, PEDIG investigators found that refractive correction alone brought about a mean improvement of 2.9 lines of vision in the affected eye of 84 amblyopic children, aged three to seven years, with previously untreated anisometropic amblyopia. In addition, mean visual acuity improved from 20/80 to 20/40, and 78 per cent of patients gained two or more lines of visual acuity, 60 per cent gained three or more lines, but even more importantly there was a resolution of amblyopia in 27 per cent of patients. Similar improvement occurred among patients with strabismic amblyopia. In patients with strabismic amblyopia alone there was a mean gain of 2.2 lines and among those with combined strabismic and anisometropic amblyopia there was a mean gain of 2.6 lines, with refractive correction alone. Most of the improvement occurred in the first 10-15 weeks of treatment but some patients continued to improve for up to 30 weeks. The severity of amblyopia did not appear to influence outcome. The amount of vision gained was similar among those with severe amblyopia and moderate amblyopia. “Optical treatment of amblyopia, or ‘refractive adaptation’ can completely address amblyopia in some children – making patching or atropine unnecessary. We can therefore conclude from the spectacle studies that, regardless of whether amblyopia is anisometropic or strabismic, treat refractive error first and follow until visual acuity stops improving,” he added. Low dose patching often effective The PEDIG studies have shown that in cases where spectacle correction does not bring about an adequate response, patching may result in further improvements. They also suggest that prescribing full-time patching is unlikely to achieve better results than prescribing part-time patching, when used as initial therapy, even in cases of severe amblyopia, Dr Holmes said. In a randomised study involving 189 patients with moderate amblyopia who underwent prescribed patching for either two hours a day or six hours a day, the two treatment groups had identical improvement throughout the study. Mean visual acuity in both groups was 20/63 at baseline, 20/40 at five weeks and 20/32 at four months. “The practical conclusion from this study is to start with two hours a day of occlusion in cases of moderate amblyopia and increase the intensity of the patching if there is an inadequate response,” Dr Holmes said. Similarly the results of another PEDIG study, which involved 175 patients, indicate that patching prescribed for six hours a day may be as effective as prescribing full-time patching in children with severe amblyopia. In the randomised trial, there was a mean improvement of 4.7 lines in the full-time patching group and 4.8 lines in the six-hour patching group. “In such cases the practical conclusion is to start with six hours a day patching and increase the intensity of treatment if there is an inadequate response,” he added. Another study suggested that the activities patients engage in during low- dose patching would have no bearing on visual improvement. The study involved 425 patients aged three to seven years with amblyopia ranging from 20/40 to 20/400 who underwent patching for two hours a day while engaging in either near or distance activities. After 17 weeks there was no statistically significant difference between the two groups in terms of visual improvement. The mean visual acuity of the amblyopic eyes in both groups improved from mean pre- treatment of 20/80 to 20/40 after treatment. In this study, children with severe amblyopia were also included, and were also prescribed patching two hours a day. Among these children with severe amblyopia (20/100 to 20/400), there was a mean improvement of 3.6 lines at 17 weeks and six patients had a complete resolution of their condition. “There is no justification for specific instructions regarding what to do when patched, other than something that takes their mind off it. And there is a role for two hours a day as initial therapy even in severe amblyopia,” Dr Holmes added. Atropine as effective as patching Atropine appears to be as effective as patching and finds higher acceptance among some parents, according to another PEDIG study. The study involved children with moderate amblyopia, visual acuity 20/40 to 20/100, who underwent either patching for at least six hours a day or daily administration of one drop of atropine every morning. At their six-month assessments the amblyopic eyes of the two treatment groups achieved similar improvements of visual acuity, with mean gains of 3.16 lines in the patching group and 2.84 in the atropine group. The proportion achieving a visual acuity of 20/30 or better, more than three lines of improvement, was 79 per cent in the patching group and 74 per cent in the atropine group. In another PEDIG study that compared daily and weekend atropine, 47 per cent of the patients in the daily group and 53 per cent in the weekend group had an amblyopic eye acuity that was either 20/25 or better or the same as or better than the sound eye acuity, suggesting that there was no advantage of daily atropine over two days a week. Yet another PEDIG study showed that adding a plano lens to atropine therapy (as initial therapy) had limited benefit over atropine alone, but found that even severe amblyopia can respond to atropine. Among 60 children three to six years of age with visual acuity of 20/125 to 20/400 in their amblyopic eye, mean visual acuity improved 4.5 lines with atropine-only and 5.1 lines with atropine plus a plano lens. Nevertheless, the more intense regimen of adding a plano lens to atropine resulted in a reduction of visual acuity in the sound eye of more than one line in 17 per cent of patients, compared to only four per cent in the group receiving atropine alone. And although all eyes returned to baseline, two patients in the atropine plus plano lens group underwent active treatment for reverse amblyopia. So if a plano lens is used in addition to atropine, careful monitoring of visual acuity is needed to avoid inducing reverse amblyopia. Previous PEDIG studies have focused on initial amblyopia therapy. Ongoing PEDIG studies are evaluating the effectiveness of A paediatric patient undergoing LASEK Courtesy of William F Astle MD, FRCSC 6 Controversies remain as amblyopic therapy enters new era of evidence-based medicine Cover Story Paediatric Ophthalmology

adding therapy in cases where amblyopia has not completely responded to initial therapy. One current study is evaluating ramping-up patching (from two to six hours a day) and a second current study is evaluating adding a plano lens to atropine. Results require cautious interpretation Although the PEDIG studies provide useful information towards designing a protocol for the treatment of amblyopia, they leave many questions unanswered, said G Robert LaRoche MD, FRCSC, Dalhousie University, Halifax, Nova Scotia, Canada. “For an ideal level of evidence, a well- run, completed randomised controlled trial with solid statistical evidence that can be clinically translated in significant new data is the recognised way to go. This is a difficult goal to achieve and it is with these qualifiers that one has to always look at data generated by clinical trials. The PEDIG studies on amblyopia are no exception to that,” he said. Questions that arise from the PEDIG reports include the effect of investigator discretion at various stages of these studies as well as the influence of patients’ compliance, and the influence of past treatment on the trial’s success. “On atropine usage, the PEDIG reports show a good acceptance, but it is also essential to know if this conclusion can be widely applied to families of different cultures, or different ethnical background. We also do not know yet what the systemic effect of long term atropine are on the patients, blood pressure included; the anecdotal evidence certainly warrants a closer look into that,” he added. Also, still unspecified is the influence of the refractive error on the effectiveness of atropine penalisation. Dr LaRoche also raised a significant concern regarding the frequent choice of subnormal visual acuity levels as success targets in the PEDIG studies on amblyopia treatment. And finally, we do not know the effect of long term success of the slower initial response to treatment that is the characteristic of the less aggressive approaches suggested by the PEDIG results. The surgical option For patients whose amblyopia has not responded to conventional treatment, refractive surgery has emerged as an option to bring about further visual improvements rendering them more amenable to refractive and occlusive response, according to three presentations at the symposium. William F Astle MD, FRCSC, Calgary Canada said that in his experience of treating paediatric patients with LASEK over the past 12 years for refractory anisometropic amblyopia, the procedure results in an overall improvement in BCVA and in stereopsis with excellent stability achieved for targeted refraction and minimal to no haze. In a study involving 53 patients with a mean age of 8.4 years who underwent LASEK after failing all other treatments, the refractive difference between the two eyes was reduced from a preoperative value of 6.89 D to 1.8 D, he said. “All clinicians should consider this therapy for children where traditional methods fail,” Dr Astle added. Merab Dvali MD, Tbilisi State Medical University, Tbilisi, Georgia reported similarly encouraging results from 10 years’ experience with hyperopic LASIK in Children with amblyopia and strabismus aged eight to 16 years. He told the symposium that in 76 of 95 amblyopic eyes he has treated with hyperopic LASIK, the condition was resolved by six to 12 months after surgery and after the same follow-up period only 12 patients had strabismus, compared to 82 preoperatively. “Paediatric LASIK simultaneously treats refractive amblyopia and accommodative strabismus in cases of hyperopia and hyperopic astigmatism,” concluded Dr Dvali. In addition, Laurence Lesueur MD, CHU Toulouse – Purpan, France, presented a 12-year follow-up study which indicated that implantation of a phakic IOL can resolve amblyopia and strabismus in about a third of patients with high unilateral myopia, without excessive risk to the intraocular structures of the growing eye. Better outcome measures needed Whatever treatment is used, a more robust definition of amblyopia and more appropriate outcome measures than are currently used will be necessary to determine their efficacy, said Alistair Fielder FRCS, FRCOphth, City University, London, UK. “Current definitions and outcome measures are not adequate because they do not reflect a physiological sense of visual pathway function and they do not promote understanding of function or the science of the condition,” he said. The standard definition of amblyopia is reduced visual function in one eye relative to the other not immediately improved by refractive correction, he noted. The measure of success in treating the condition is generally the amount of visual improvement in the affected eye, Dr Fielder continued. “In a physiological sense, a successful outcome is achievement of that condition which is best suited to promote a normal or optimal visual development and function, and that means equal visual input. Thus, optimum outcome for amblyopia therapy is when vision of amblyopic eye equals that of the fellow eye,” Dr Fielder added. However, a true cure for amblyopia requires more than just an improvement of visual acuity in the affected eye, said John Sloper FRCS, FRCOphth, Moorfields Eye Hospital, London, UK. Amblyopia involves defects in several other aspects of vision that are affected by abnormal neural development and abnormal neural processing of visual stimuli. In particular, he noted that in primate studies of amblyopia where one eye is deprived of visual stimulation, there develops an imbalance between the parvocellular pathway, which seems to be concerned primarily with perception of colour and fine detail, and the magnocellular pathway which is more involved with the visual perception of large moving objects. The two pathways work in parallel with each other, and primate studies show that when compared to normal lateral geniculate bodies, those of animals whose eyes were occluded from birth have parvocellular cells that are smaller relative to magnocellular cells for both the amblyopic and the fellow eyes. Electrophysiological studies of patients with strabismic amblyopia show abnormalities of visual evoked potentials which are different for coloured and moving stimuli, suggesting that such patients also have different changes in their magnocellular and parvocellular pathways. This raises the questions of whether some children fail to respond to patching because of an imbalance between these pathways and whether we should be looking selectively to stimulate magnocellular or parvocellular pathways as part of amblyopia treatment? holmes.jonathan@mayo.edu Patricia.Pontbriand@iwk.nshealth.ca william.astle@albertahealthservices.ca modernoptics@hotmail.com laurence.lesueur@club-internet.fr a.fielder@city.ac.uk John.sloper@moorfields.nhs.uk 7 Courtesy of Laurence Lesueur MD Cover Story Paediatric Ophthalmology Jonathan HolmesWilliam F AstleMerab DvaliLaurence Lesueur Courtesy of Merab Dvali MD

This is a lively time in the field of paediatric ophthalmology, with important new studies in many key areas including genetics, strabismus, retina, cataract and refractive surgery. These topics were on display at the 1st World Congress of Paediatric Ophthalmology and Strabismus (WCPOS), which was held in Barcelona in conjunction with the annual congress of the ESCRS. Attendance at the paediatric conference exceeded all expectations, with delegates from all around the world. EuroTimes editor Sean Henahan spoke to David Granet MD, co-chair/founder of WCPOS, and director of the Ratner Children’s Eye Centre in La Jolla, California, about current research in the field. Q: What was the raison d’etre for the 1st World Congress of Paediatric Ophthalmology and Strabismus? A: Dr Ken Nischal and I thought it was time for the world to get together. We feel strongly that expertise does not reside in only one region of the world. The idea of putting the best people together in one room to talk about paediatric ophthalmology was irresistible. We felt it was important to have a meeting that included speakers from around the world. This is the beginning of what we hope will be regular opportunities for people to get together and talk. We were very excited by the level of freedom that the ESCRS gave us to be able to have controversies, case presentations and discussions – every manner of learning experience – at the conference. We gave our moderators the freedom to run sessions the way they would want to experience them if they were in the audience. We went beyond the format of just getting up and talking at people for 10 minutes, making it more dynamic and interactive. We had experts from every region moderating the sessions. What we were doing has never been done before. Q: What are the general trends and current and future concerns in this field? A: The conference highlighted many of the ongoing controversies. The biggest trend is probably genetics, whether it is stem cells or the diagnosis of genetic diseases. These genetic disorders occur in children, and affect them as they grow. This is an area where we will be able to make a difference, intervening in the early stages of disease. Gene therapy has made quantum leaps in the past decade. This was science fiction a short while ago. Now it is happening. These genetic disorders used to be a sort of visual death sentence. Now we’re talking to parents, getting genetic testing, identifying a gene locus, putting them in a gene bank, and alerting them when treatment is available. Studies in the US and UK confirm you can transfer a gene into the retina and have it function. It is astounding that we can do this. We expect to see gene therapy for inherited retinal disease. We may be able to grow retinas outside the body and implant them. We have a lot of new techniques and approaches in many areas including strabismus, amblyopia, glaucoma and particularly cataract and refractive surgery in children. This touches on a controversial area, the interaction between adult and paediatric ophthalmologists. We want to take the skills and techniques that the adults have, and the information that the paediatric specialists have, and put those together and end up with something way better. This has been the trend over the last 10 years. Finally enhancing the knowledge base of some specialists that have been unable to attend meetings before was crucial to the success of the meeting. Q: There does seem to be a divide, at times, between the adult and paediatric specialists. For example, how do you sort out who does what in cataract cases? A: We were fortunate at the conference to get some of the best people from both worlds together. The joint ESCRS/ WCPOS session was a resounding hit. To me the controversy is not that controversial because the people who can do procedures are the ones who should be doing them. That can be a general ophthalmologist in the right setting, where perhaps there isn’t a paediatric ophthalmologist who is comfortable doing a particular procedure. An adult ophthalmologist may work with a paediatric ophthalmologist to make sure that refractive errors are taken care of properly. There are also situations where a paediatric ophthalmologist who is comfortable in that setting can take care of it as well. The adult ophthalmologists can get corneal curvatures in office without any problem. We see patients where we can’t even get Ks… we need to guess. We’re dealing with completely different situations in terms of ability to generate information. In adults you are aiming for a known refraction, you say I want this person to be slightly myopic or to end up perfect at distance. A kid is going to grow, so we aim differently if they are six months or one month, or two years old. Do you insert an implant at six months of age? Will we end up with more glaucoma if we do? What complications will we see doing surgery in a six-week-old? The capsule is completely different than in a 60-year-old. Handling the capsule is important. What do you do with the posterior capsule, leave it or take it? How do you take it, anteriorly, pars plana? These things can be handled in so many different ways. If your bias is adult cataract surgery you will come at these problems completely differently than if your bias is paediatric surgery. There is no doubt that the paediatric people know the paediatric side better and the cataract people know the cataract side better, but there is a way to communicate better, and that is what this is about. We might not talk so much about where we disagree or differ, but actually where we can get together. We want to find the common ground, and help each other develop the skills, so that the child ends up with the best possible care. Q: On the refractive side, it used to be a taboo to even consider a laser refractive procedure in a paediatric patient, but now that seems to be changing. A: Yes it is. We may wake up in 15 years and find that refractive surgery is standard of care. The problem is getting from where we are to where we need to go. We need to talk to refractive surgeons who are very comfortable with refractive surgery and get them together with paediatric surgeons who are uncomfortable with refractive surgery. The information that the refractive surgeons have about the technology and how to apply it, along with the experience of thousands of cases, needs to be combined with our knowledge of the paediatric eye. There are some appealing and intriguing approaches to using refractive surgery in the paediatric setting, such as high myopia, and amblyopic anisometropia. We’re worried about these kids who will have to live with the results for 70 years. We are also worried that once we open that door that there will be a stampede of parents running through who want their 11-year-old to get rid of glasses for mild myopia. We want to be very careful about that. We want to avoid lasering anyone too frequently, too young, in the wrong settings. Once again this highlights the need for good communication. Whether it is between specialties or intra specialty that is crucial. The World Congress and the World Society are really ideas whose time has come. Ken Nischal and I are humbled to have had the opportunity to help facilitate this seminal first gathering. dgranet@ucsd.edu 8 David Granet Exciting times for paediatric ophthalmology as new congress brings experts together Paediatric Ophthalmology Newsmaker Interview

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Dermot McGrath in Manama A MAJOR coordinated effort is needed to tackle the underlying causes of blindness in children, particularly in poorer and underdeveloped regions where the needs are greatest, according to a leading expert in the field. Clare Gilbert FRCOphth, MD, International Centre for Eye Health at the London School of Hygiene and Tropical Medicine, told delegates attending the MEACO Congress that blindness in children is a major, lifelong, problem in every part of the world, affecting not just the affected children, but also their families, their communities and countries. “It is the greatest problem where resources are least,” said Dr Gilbert, who said that WHO statistics show that there are about 1.4 million blind children in the world. “When we consider that the total figure for adult blindness is 45 million, this figure looks like a very small number. But one has to bear in mind that these children have a lifetime of blindness ahead of them.” Dr Gilbert said that successive studies have demonstrated the clear link between childhood blindness and poverty. “There are two principal reasons for this. First, the population of children in poorer regions is much higher, and secondly, the prevalence of blindness in children in these countries is much higher,” she said. She noted that the available evidence seems to suggest that the majority of the 1.4 million children are either born blind or become blind before six years of age. “This tells us that in terms of controlling childhood blindness that we really need to focus our efforts and resources on children aged zero to five,” she said. Dr Gilbert said that other studies clearly indicate that blind children have a higher mortality rate than sighted children and that around 45 per cent of the causes of blindness are avoidable. “By ‘avoidable’ I mean that they are entirely preventable or they have conditions where the children could be treated in order to restore visual function,” she said. Dr Gilbert noted that control is a priority for Vision 2020 and that specific control measures are needed for children. “We know from experience that if programmes are simply focused on adults, then children will invariably fall through the net and they won’t have access to the services that they need,” she said. In looking at the underlying causes of blindness in children, Dr Gilbert said that there are three variables - society, primary healthcare and specialised services - that need to be taken into consideration if the problem is to be tackled effectively. Not surprisingly, the mortality rate in children is closely linked to the economic situation of the country they live in, she said. “This is because the level of poverty and services in a particular region determine what diseases occur in populations and this is also extremely true of the blinding diseases of childhood,” she said. Using data drawn from studies of 20,000 blind children in over 40 countries, Dr Gilbert said that it was possible to show schematically that the majority of children in high-income countries are primarily affected by unavoidable causes of blindness, whereas in very poor countries, about one third of children are blind from corneal scarring, with a high prevalence of cataract and glaucoma. Looking at the underlying causes of blindness, Dr Gilbert said the key lay in addressing issues of economic development. “We need interventions and policies in these countries to promote economic development. Female education is also massively protective of child health and visual loss in children and helping to avoid harmful practices,” she said. Assessing the apparently blind baby Susan H Day MD discussed the multi- faceted role of the ophthalmologist in assessing apparently blind paediatric patients in a separate presentation. Dr Day, chair of the Department of Ophthalmology at the California Pacific Medical Centre, as well as a paediatric ophthalmologist in private practice, identified four main responsibilities for the ophthalmologist in assessing the apparently blind baby. “Firstly, we need to hear the parents’ concerns and clarify historical information about the baby. We also need to refine the differential diagnosis, which means reflecting on common conditions, examining the baby, looking for treatable causes, identifying systemic implications and determining additional testing. Finally, we need to counsel the family,” she said. In terms of symptoms of blindness, Dr Day said that ophthalmologists should look for signs of nystagmus, which is age-dependent, eye poking, presence of strabismus or obvious structural abnormality. To clarify the historical information, the baby’s perinatal history, family history, systemic health and possibility of trauma needs to be taken into account, said Dr Day. Examination of the baby should include assessment of fixation, vestibulo-ocular reflex (VOR), retinoscope examination and assessment of the fundus with direct and indirect ophthalmoscopy. Treatable causes of blindness cited by Dr Day included cataract, congenital glaucoma, retinoblastoma, retinopathy of prematurity, refractive error and chiasmal syndrome. She also advised watching for conditions that might be treatable in the future such as retinal dysplasias and profound amblyopia. In counselling the family, Dr Day stressed the importance of avoiding definitive statements. “We have to convey that one visit cannot usually predict precisely the diagnosis. We need to focus on the whole child, emphasise key points, provide references and information for the parents, and enable them to network with similarly affected families. Above all, we need to provide hope yet be realistic,” she concluded. Clare.Gilbert@Lshtm.ac.uk days@sutterhealth.org 10 Concerted effort needed to combat paediatric blindness Special Focus Paediatric Ophthalmology Don’t Miss Practice Development Page 36

Cheryl Guttman in Barcelona IN 1997 at Hinchingbrooke Hospital, Helen Gibbons MSC, RGN, became the first ophthalmic nurse in the UK to perform YAG laser capsulotomy. More than 10 years later, this expanded role has been taken on by a limited number of nurse practitioners. However, controversy exists both within the nursing profession and among ophthalmologists about in whose hands this procedure belongs. In a point- counterpoint session at the annual meeting of the European Society of Ophthalmic Nurses and Technicians (ESONT), Ms Gibbons outlined reasons why more nurses should be seeking to take on this role and described a training programme she has been involved in developing at Moorfields where she recently transferred. Ms Gibbons explained that nurse- performed YAG laser capsulotomy improves efficiency and continuity in patient care, both of which lead to increased patient satisfaction. There are benefits for the nurse as well who derives increased job satisfaction from witnessing the immediate improvement in a patient’s vision and by gaining opportunities for subspecialty interest development. Moreover, these advantages are achieved without downsides for the patients or physicians. “Ophthalmologists need not feel their jobs are threatened because there are plenty of patients needing YAG laser capsulotomy to go around. Some ophthalmologists may contend that nurses are slower in performing the procedure because they are more cautious, but patients often appreciate this extra care, and as they gain experience, nurses can be just as efficient as physicians,” said Ms Gibbons. Ms Gibbons told attendees she has performed more than 1500 procedures, and a personal audit of 50 cases demonstrates excellent results. Forty-nine (98 per cent) patients achieved a visual outcome post-YAG capsulotomy that was the same or better than their best post-cataract surgery VA. The single exception was a patient whose VA was 6/6 after cataract surgery, 6/36 prior to YAG capsulotomy, and 6/12 after the procedure. The only complication encountered was raised IOP in a patient with glaucoma, and patient surveys showed 100 per cent satisfaction in the service as well as 100 per cent confidence. Now, five senior band 7 nurses at Moorfields Eye Hospital are about to begin training for YAG laser capsulotomy. The nurses already have specialist slit lamp skills, and each will be assigned to training by a cataract consultant. Eligibility for independent practice requires that each nurse completes 30 procedures under supervision. “This condition is a safety measure and intends to build nurse confidence. Going forward, each nurse will be reviewed on an annual basis to ensure high standards of care are maintained,” said Ms Gibbons. The training that will qualify the Moorfields nurses is a robust programme developed by a working party comprised of the lead consultant, director of nursing, risk managers, and the first nurses involved. Input was also obtained from personnel in the risk and clinical governance departments, and it was necessary to ensure that patient group directions for administering topical ophthalmic medications were in place since not all of the nurses are prescribers. They also needed to have completed a course on informed consent and a laser safety training session. Additional training covers the risks and legal implications of the extended role, video- recorded role playing for obtaining patient consent, an update on the pharmacology of medications used for the procedure, and information about the technique, criteria for patient selection, including recognising patients at higher risk for complications, and potential complications. According to the Moorfields protocol, all patients who will be treated by a nurse have already had an eye exam by a physician and their chart includes documentation on the appearance of the macula and current comorbidities. Need for a physician’s expertise Aiming to convince audience members that YAG laser capsulotomy for PCO should remain solely within the purview of physicians, Tayo Akingbehin MD, FRCS, FRCOphth, of iSIGHT Clinics, England, UK, underscored that the treatment protocol and follow-up should be individualised for each case based on medical judgement. “YAG laser capsulotomy is an outpatient procedure that is said to be simple, safe and effective. However, there are many variations in the way the procedure is done and postoperative treatment can vary. Therefore, it is difficult to design a single streamlined, straightforward protocol for nurses or technicians to follow,” he said. Questions that need to be considered include whether and with what to administer IOP-lowering agents and anti-inflammatory drops and if the patient should return for a visit, to who, and how many times. “These are all decisions that cannot be made in advance,” said Dr Akingbehin. To illustrate the need for a tailored approach, Dr Akingbehin presented a series of cases highlighting the issues that can be encountered and may influence patient management. For example, the adequacy of pupil dilation, density and nature of the PCO, and type of IOL and time post-implantation must be taken into account in determining if and how to perform the capsulotomy. The size of the capsulotomy, if too small, will produce visual disability in mesopic conditions eg, glare, haloes and diplopia. Postoperative management must consider the amount of energy used and the patient’s ocular and medical history. In addition, this ‘simple’ procedure has a number of potential risks. These include IOL optic damage, raised IOP, corneal oedema, and cystoid macular oedema. Retinal breaks or detachments, floaters, and glare at night can also occur. “Complications need management, and the person delivering care should have experience in knowing what to do,” said Dr Akingbehin. A champion for the nurse Declan W Flanagan, consultant ophthalmic surgeon and deputy medical director, Moorfields Eye Hospital, trained Ms Gibbons at Hinchingbrooke, and he remains convinced that the practitioners performing this procedure can come from disciplines outside ophthalmology as long as they have the appropriate training and support. He emphasised that nurses trained to perform YAG laser capsulotomy must meet competencies currently in the Royal College of Ophthalmologists Ophthalmic curriculum and that doctors make the decision to treat and are always immediately available while the procedure is done. “In practice in the UK, most YAG laser capsulotomies are performed by relatively junior ophthalmic surgical trainees with varying degrees of supervision. Trained nurses and optometrists can provide this service in a clinically and cost effective fashion that at least matches the service provided by trainee ophthalmic surgeons,” Dr Flanagan said to EuroTimes. “In fact, Ms Gibbons’ audited outcomes and patient satisfaction surveys compare favourably with the best published outcomes data.” Helen.Gibbons.1@city.ac.uk; declan.flanagan@moorfields.nhs.uk tayo@isightclinics.com Small size capsulotomy YAG laser capsulotomyCystoid Macular Oedema Courtesy of Tayo Akingbehin MD, FRCS, FRCOphth Courtesy of Helen Gibbons MSC, RGN 12 Helen GibbonsTayo Akingbehin Nurse-performed YAG laser capsulotomy offers benefits, but controversy remain Cataract Update

Howard Larkin in Barcelona A STUDY of two protocols for diluting cefuroxime for intracameral injection found a significant difference in accuracy between them, and an unacceptably wide range of variability within one. The results suggest that mixing antibiotics in 1.0ml syringes should be avoided. They also point to a need for developing robust preparation protocols and regularly auditing them to ensure the efficacy and safety of endophthalmitis antibiotic prophylaxis injections, presenters told a symposium at the XXVII Congress of the European Society of Cataract and Refractive Surgeons. “It is our assertion that protocols for intracameral antibiotic preparations should be audited both to ensure clinical accuracy and an acceptable range of variability. This knowledge can reassure and minimise dosage concerns,” said David Lockington MRCOphth, Tennent Institute of Ophthalmology, Glasgow, UK, who conducted the study with colleagues at Glasgow University and the University of Strathclyde, both in the UK. Safety concerns slow practice shift Despite the landmark ESCRS survey (Barry et al J Cataract Refractive Surgery 2006; 32:407-410) and studies from the Swedish National Cataract Registry that demonstrated the efficacy of intracameral cefuroxime in reducing postoperative endophthalmitis risk, many surgeons around the world still do not use prophylactic antibiotic injections. Safety concerns related to compounding antibiotics in the minute quantities required for ophthalmic use appear a major reason why. Dr Lockington cited a 2007 survey of American Society of Cataract and Refractive Surgery members that reported significant concerns about “homemade intracameral antibiotic preparations”. This study found that only six per cent switched to injected cefuroxime as a result of the ESCRS study while 77 per cent of the 1,312 respondents said they had not changed their practice. However, 30 per cent reported using intracameral antibiotics either as an injection or in irrigating solutions (Chang et al J Cataract Refractive Surg 2007; 33:1801-1805). Such reservations are by no means limited to US surgeons. A 2008 survey of members of the United Kingdom and Ireland Society of Cataract and Refractive Surgeons found that 45 per cent of 98 responding members did not use intracameral cefuroxime. Of those non-users, 68 per cent reported their main concern was the risk for dilution errors in the absence of a commercially pre-formulated preparation, with 67 per cent stating they would switch if such a product became available (Gore et al J Cataract Refract Surg 2009 Apr;35(4):770-3). Similarly, in the 2008 annual survey of ESCRS members by David V Leaming MD (www.analeyz.com, retrieved Sept 30, 2009), 57 per cent reported using intracameral antibiotic injections. That’s up from 52 per cent in 2007, but still far short of a unanimous vote of confidence. The recipe matters Dr Lockington noted that two hospitals in his area used two very different protocols for preparing intracameral cefuroxime, raising questions about the accuracy and variability of antibiotic dilution. “In light of that we thought we should look at the recipes,” Dr Lockington said. Both protocols start with a 250mg vial of cefuroxime and then dilute it so the surgeon can inject 1.0mg in 0.1ml saline at surgery. Protocol 1 added 12.5ml saline to the cefuroxime and then withdrew 1.0ml of the solution into a 2.0ml syringe. To this 2.0ml syringe was added 1.0ml of saline. From this, 0.5ml was drawn up into a 1.0ml syringe, of which 0.3ml was discarded and 0.2ml delivered to the surgeon. Protocol 2 added 2.5ml saline to the cefuroxime and then withdrew 0.1ml of the solution into a 1.0ml syringe. Another 0.9ml saline was drawn into the 1.0ml syringe, of which 0.8ml was discarded and 0.2ml delivered to the surgeon. “The critical difference is that protocol 1 dissolves antibiotic in a larger volume and mixes it in a larger syringe,” Dr Lockington said. To test the dilution levels produced by each protocol, Dr Lockington used analytic- grade potassium chloride as a surrogate for the antibiotic. This enabled dilutions to be compared among samples using flame photometry. Both protocols were followed by 10 ophthalmic theatre staff from each hospital, and by 10 analytic chemists. A total of 30 samples for each protocol, 10 each from the three test groups, were analysed to determine the accuracy and consistency of dilution. In terms of the ability of the theatre staff and chemists to accurately follow the two protocols, no significant differences in dilution levels or variations were found among the groups whether they followed their familiar protocol or an unfamiliar process. However, protocol 1 demonstrated much greater accuracy of dilution achieved across all test groups, ranging from 0.62mg to 1.77mg per 0.1ml saline, compared with 0.52 to 7.25mg for protocol 2. At 2.05mg/0.1ml, the median concentration in protocol 2 also was much higher than the 1.17mg for protocol 1, a finding found significant at p<0.001. “This shows that the mathematical accuracy of the protocol does not correspond with clinical accuracy in dosage,” Dr Lockington said. The study team expected some variation due to the difficulty of injecting 0.1ml of any solution, Dr Lockington said. The paediatric and diabetes literature suggest a 10 per cent error volumetrically at this dosage, he said. However, the comparison generated a much wider variation between the two protocols, which Dr Lockington believes is due to the difficulty of mixing in a 1.0ml syringe. “If you are used to intravitreal injections and you have tried to flick an air bubble out of a 1.0ml syringe, you know how difficult that is. So it shouldn’t surprise you that fluids do not mix well in such a small volume,” he said. Dr Lockington demonstrated the difficulty using food colouring in a 1.0ml syringe. Even after vigorous mixing, it showed a gradient of concentration, which he said supports his hypothesis. Dr Lockington concluded that protocol 1 demonstrated an acceptable range of variability, and that mixing antibiotics in 1ml syringes should be avoided. Further research should be done to develop reliable mixing protocols, and regular audits should be conducted to ensure clinically accurate doses are delivered, he added. Understanding the concentration of what is being injected into the eye is also important to avoid toxic anterior segment syndrome, commented Nick Mamalis MD, Salt Lake City, Utah, US. “This shows the difficulty of getting an ideal mix and concentration. It is something we all need to look at if we do intracameral injections.” davidlockington@hotmail.com nick.mamalis@hsc.utah.edu 13 Audited protocols are needed to reliably mix intracameral cefuroxime David LockingtonNick Mamalis Cataract Update

By Cheryl Guttman in Barcelona INTRAOPERATIVE wavefront aberrometry is a valuable asset for improving the refractive and visual outcomes of patients with significant pre- existing astigmatism undergoing cataract surgery, reported investigators at the XXVII Congress of the ESCRS. ORange provides real-time analysis of cylinder, allowing surgeons to make and enhance limbal relaxing incisions (LRIs) as needed. In comparative studies, the ORange Intraoperative Wavefront Aberrometer (Wavetec Vision) reduced residual cylinder to provide improved vision outcomes, reported Edward Holland MD, professor of ophthalmology, University of Cincinnati, and director, cornea service, Cincinnati Eye Institute, Cincinnati, Ohio. The potential value of a method to improve the accuracy of LRIs is clear considering the size of the target population that are candidates for astigmatic correction at the time of cataract surgery and the imprecision of the current surgical technique, noted Dr Holland. “A study conducted by Warren Hill MD, showed that more than half of 6,000 patients undergoing cataract surgery had more than 0.75 D of pre-existing astigmatism. Relaxing incisions have been the most common method for managing this astigmatism to improve visual outcomes, but the results can be unpredictable,” said Dr Holland, He reported data from a manufacturer- sponsored trial conducted at the first 10 sites in the US where the ORange device was commercially available. The study cohort consisted of 94 patients who underwent LRIs with intraoperative wavefront guidance evaluation and 189 historical controls operated on by the same surgeons without use of this technology. Mean cylinder preoperatively was the same in the ORange group and controls, 1.45 D and 1.47 D, respectively. Intraoperative aberrometry resulted in enhancement of the LRI in 39 per cent of patients in the ORange group. At 30 days post-op, the ORange group had a lower mean cylinder value, 0.47 D vs. 0.7 D, as well as a lower rate of “surgical surprises”, defined as >1.5 D of residual cylinder at 30 days, zero per cent vs. eight per cent, reported Dr Holland. Preliminary data from an ongoing prospective randomised clinical study currently under way at the Cincinnati Eye Institute are corroborating the multicentre trial results. Analyses for 10 eyes that were evaluated intraoperatively with ORange and 10 controls show the two groups were similar in their mean pre- existing cylinder, 1.36 D vs. 1.37 D. Postoperatively, both groups achieved good outcomes with mean residual cylinder values <0.5 D. However, UCVA was superior in the ORange group where the proportion of patients achieving 20/20 or better was twofold higher compared with the controls, 40 per cent vs. 20 per cent, respectively. Further evidence of the benefit of this technology was provided by a retrospective analysis conducted by Mark Packer MD, showing intraoperative wavefront-guidance of LRIs reduced the rate of postoperative excimer laser enhancement by almost six-fold The study conducted by Dr Packer, clinical associate professor of ophthalmology, Oregon Health & Sciences University, Eugene, included eyes that had cataract or refractive lens exchange surgery with intraoperative LRIs between May 2007 and June 2009. There were 37 eyes of 27 patients operated on without ORange during the first 15 months of the study period and 30 eyes of 21 patients that had surgery with ORange guidance beginning in August 2008. In the ORange group, eight eyes (26.7 per cent) of six patients had intraoperative enhancement by LRI extension. At about one month postoperatively, mean refractive cylinder was 0.48 D in the control eyes, 0.37 D in the ORange group, and 0.31 D for the eight ORange eyes that had intraoperative LRI enhancement. Outcomes in the control and ORange groups were similar with respect to mean sphere (-0.27 vs. -0.33 D), mean MRSE (+0.00 vs. -0.15 D), and median UCVA (20/25 both groups). However, only one of 30 eyes (3.3 per cent) in the ORange group underwent excimer laser enhancement compared with six of 37 eyes in the control group (16.2 per cent; odds ratio = 5.71, p=0.12), Dr Packer reported. “The fact that MRSE at one month was about the same if not a little worse in the ORange group shows clearly that need for postoperative laser enhancement was related to cylinder and not SE. Although the reduction in rate of laser enhancements does not quite reach statistical significance, this is a small case- controlled study and there is a positive trend. Further research is needed in the form of a prospective randomised study to validate the benefit,” said Dr Packer. There were no significant differences between the controls and ORange patients in their mean age or mean values for preoperative delta K (1.5 D vs. 1.28 D), steep axis (83 vs. 87 deg), or peripheral pachymetry (679 vs. 668 microns). In the ORange group, intraoperative enhancements were performed by extending the arcs if the measured axis was reasonable (within 15 degrees of expected) and residual cylinder was 1 D or greater. Otherwise, the same methods for planning and creating the LRIs were used throughout the study period. While mean refractive cylinder at one month postoperatively was <0.50 D in both study groups, the lower rate of excimer laser enhancement in the ORange group can be understood by stratifying eyes based on amount of residual cylinder and the observation that 1 D of residual cylinder appeared to be a “watershed” for performing postoperative excimer laser enhancement. At least 1 D or greater cylinder was present in 24 per cent of controls and only 6.6 per cent of ORange eyes, and residual cylinder was 1.25 D or more in 11 per cent of controls compared with only 3.3 per cent of ORange eyes. No ORange eyes had more than 1.25 D of residual cylinder while the range was up to 1.75 D in the controls. For the non-ORange eyes, the mean post-excimer manifest cylinder at 7-16 months was 0.95 D. Refraction was not performed in the ORange group patient that had laser enhancement, but UCVA was 20/20. “These data demonstrate substantive value for Orange. Reduction of the enhancement rate provides both tangible and intangible benefits for surgeons and patients,” Dr Packer said. mpacker@finemd.com eholland@fuse.net Courtesy of Mark Packer MD 14 Edward Holland Intraoperative wavefront aberrometry valuable for enhancing LRI outcomes Cataract Update Mark Packer

Howard Larkin in Barcelona OVER the past 11 years the percentage of foldable intraocular lenses (IOLs) explanted due to incorrect lens power has trended steadily downward, reported Nick Mamalis MD at the XXVII Congress of the ESCRS. “I think this speaks to the fact that we have better methods of measuring for IOLs that result in putting in the correct power lens in the first place,” said Dr Mamalis, who conducts the annual ASCRS/ESCRS survey of foldable IOLs requiring explantation or secondary intervention. Responses to the online survey are received from surgeons around the world. On the other hand, lens dislocation and decentration were once again the leading causes of lens explantation overall in the 11th annual survey, which covered events reported during calendar year 2008, said Dr Mamalis, professor of ophthalmology, Moran Eye Centre, University of Utah, Salt Lake City. This finding is consistent with other studies suggesting that lens dislocation rates have risen as more lenses are implanted in the posterior chamber, including a 2005 report by Gimbel and colleagues on late dislocations (J Cataract Refract Surg. 2005; 31(11):2193-204). A July 2007 overview by Wu and colleagues estimates the overall incidence of lens dislocations in the US at 0.2 per cent to 1.8 per cent of cataract surgery cases (emedicine. medscape.com/article/1211310-overview). While the primary purpose of the ASCRS/ ESCRS explantation survey is to monitor the performance of various IOL materials and designs over time, Dr Mamalis believes many lens dislocations could be avoided with improved surgical technique. “A lot of cases of decentration are not due to problems with the implants, but problems in the surgery where the implant is not placed symmetrically in the bag. We surgeons can prevent this by making certain we have a well- fixated implant in the bag, and a well-centred and properly sized capsulorhexis.” The 2008 survey breaks out results by lens material; including hydrophobic acrylic, hydrophilic acrylic and silicone; as well as design, including three-piece, one-piece plate, one-piece with haptics, and multifocal regardless of fixation mechanism. Glare and optical aberrations were the second most common reasons for explantation overall. But as in previous surveys, the problems leading to explants also varied considerably by lens design and material, Dr Mamalis noted. For example, dysphotopsias/optical aberrations were a major complaint in 100 per cent of explants of multifocal lenses, Dr Mamalis said. “In terms of multifocal lenses, proper patient selection and counselling is critical. A lot of the problems have to do with glare and visual aberrations. We need to choose patients carefully and counsel them carefully to avoid the need for explanting these lenses.” At 14 per cent of the total, multifocal lenses also make up a growing proportion of explants reported, Dr Mamalis said. However, he believes this increase is because more multifocals are being implanted than from an inherent problem with their design. Similarly, calcification/ opacification was a factor in all explants of hydrophilic acrylic, or hydrogel, lenses reported in 2008, Dr Mamalis reported. “Some of the lenses that tended to calcify are no longer being placed in the eye and are no longer being distributed. Hopefully with time and further surveys we will see this drop off.” However, in a separate symposium, David J Apple MD, Sullivan’s Island, South Carolina, US, noted that while improvements have been made in lens design, there might still be issues with hydrophilic acrylic as a lens material. The issue with primary calcification is gone, he said. However, secondary calcification still frequently appears in patients with diseases or conditions that affect aqueous chemistry or disrupt the aqueous blood barrier, such as diabetes, and problems with the implant surgery. Because it is impossible to predict which patients will get secondary calcification, it may be prudent to avoid implanting hydrophilic lenses in patients with existing disease, he said. Hydrophobic acrylic was the most common lens material reported, making up 61 per cent of all lenses in the ASCRS/ESCRS study. Among one-piece with haptics monofocal hydrophobic acrylic lenses, which accounted for 28 per cent of all lenses reported, about 28 per cent were explanted due to decentration/ dislocation and about 19 per cent for glare/optical aberrations. Among monofocal three-piece acrylic lenses, which made up 23 per cent of the total study sample, about 35 per cent were removed for decentration and about 20 per cent for glare. About 10 per cent of both designs were removed for incorrect lens power. Dr Mamalis stressed the importance of reporting lens explanations and the reasons for them to get a clearer idea of what complications are associated with specific materials and designs. Results of the study, which is conducted in conjunction with the ESCRS and ASCRS, and the ASCRS Cataract Clinical Committee, are reported annually. Survey reports can be filled out online at the ESCRS and ASCRS websites (www.escrs.org, www.ascrs.org). nick.mamalis@hsc.utah.edu :LWKD\HDUWUDFNUHFRUGDQGPRUHWKDQ PLOOLRQVXUJHULHVZRUOGZLGH9LVLRQ%OXHŠ KDVEHFRPHWKHVWDQGDUGRIFDUHIRUVDIHO\ VWDLQLQJFDWDUDFWVIRUHQKDQFHGYLVXDOL]DWLRQ RIWKHFDSVXORUKH[LV7KLVLVWKHUHVXOWRIWLPH DQGFRVWLQWHQVLYHUHVHDUFKZRUNSURWHFWHGE\ (XURSHDQDQG86SDWHQWV7KLVSDWHQWSURWHFWLRQ PHDQVWKDW'25&ZLWK9LVLRQ%OXHŠLVWKHRQO\ FRPSDQ\LQ(XURSH DQG86 WKDWOHJDOO\FDQ SURPRWHDQGVHOOFDWDUDFWVWDLQLQJVROXWLRQ WRYLVXDOL]HWKHFDSVXORUKH[LV )2&86219,6,21%/8(Š 3529(148$/,7<3527(&7(' &RQWDFWXVWROHDUQPRUH RUWRDUUDQJHIRUDVXUJLFDO GHPRQVWUDWLRQ '25&,QWHUQDWLRQDO%9 6FKHLMGHOYHZHJ 91=XLGODQG 7KH1HWKHUODQGV 3KRQH )D[ 3$7(17 3527(&7(' 15 IOL explant survey finds lens power errors are down but dislocation is rising Cataract Update Nick Mamalis

Devon Schuyler in New York AN EXPERIMENTAL device called an episcleral drug reservoir could allow painless, continuous delivery of drugs into the eye over a period of weeks or months. “We could potentially use this to treat macular degeneration, diabetic retinopathy, retinopathy of prematurity, uveitis, endophthalmitis, retinoblastoma and glaucoma,” said A Linn Murphree MD, co-developer of the episcleral drug reservoir with 3T Ophthalmics in Irvine, California. Dr Murphree is professor of ophthalmology and paediatrics at Doheny Eye Centre and affiliated with the Vision Centre at Children’s Hospital Los Angeles. “Any eye disease that needs chronic treatment could benefit,” he said. Delivering medication directly to the eye has numerous benefits over injections, which are painful, often require monthly retreatment, and can cause complications like infection, retinal detachment and bleeding. Local drug delivery has fewer side effects than administering a drug systemically. Episcleral implants also have the advantage of perfect compliance, a goal that’s difficult with eye drops. Researchers are also developing several intravitreal implants, but these require more extensive surgery for implantation and removal. The 3T reservoir is made of silicone and looks like a tiny bathtub less than 1.0cm long. It can be filled with medication in any form — including gel, liquid or matrix — before being inverted and placed on the episclera through a small incision in the conjunctiva. A drop of bioadhesive or an episcleral suture seals the incision. As many as four devices could be placed in each eye to deliver different drugs, which enter the eye by diffusing through the episclera. When the device runs out of medication, the ophthalmologist has the option of injecting new medication into the reservoir via a refill port, replacing the implant with a newer one, or leaving the empty implant in place and adding another reservoir. If no additional medication is needed, the surgeon can either remove the reservoir or leave it in place. Dr Murphree has an RAID (Rapid Access to Interventional Development) grant from the US National Institutes of Health to test the device for use in patients with retinoblastoma. Retinoblastoma patients currently need to be treated with a series of chemotherapy infusions that cause side effects throughout the body. By administering the chemotherapy drugs through the sclera, Dr Murphree hopes to treat the disease with much greater efficacy and fewer side effects. “We have a particularly hard time eliminating tumours with systemic chemotherapy, and we know that chemotherapy works better when it’s not episodic,” he said. He’s awaiting FDA approval to begin clinical trials of the device in eyes that otherwise need to be removed. Another device that’s in clinical trials is the LX201, a silicone matrix episcleral implant that’s designed to deliver cyclosporine A to the eye’s surface for a full year. In March, Lux Biosciences of Jersey City, New Jersey and Frankfurt, Germany, completed enrolment in a phase III trial to prevent corneal transplant rejection. The company is also developing bioerodible polymer implants for potential use in severe dry eye, macular degeneration and diabetic macular oedema. Challenges in living patients Karl G Csaky MD, the T Boone Pickens Chair for research in macular degeneration at the Retina Foundation of the Southwest in Dallas, Texas, who has studied the LX201 device, said that the 3T device may have the advantage for delivery of drugs into the eye because it delivers drugs in a unidirectional manner. “The drug isn’t being potentially wasted by coming out the side facing away from the sclera,” he said. But the fact that most ophthalmologic drugs need to penetrate the sclera – rather than simply sitting on the eye’s surface – poses special challenges. “In most studies of episcleral drug administration, less than one per cent of the drug gets inside the eye,” he said. This is a big problem when the drug needs to reach the choroid or retina to be effective. Dr Murphree pointed out that most drugs pass easily through the sclera in animal studies. Even drugs with a molecular weight of 150 kilodaltons have been shown to pass through the human sclera. But Dr Csaky said that these laboratory studies don’t reflect how the drugs will act in a living human. He said that even though the sclera doesn’t pose an anatomic barrier, physiologic mechanisms appears to reduce the absorption of medication. For example, the tight junctions of the retinal pigment epithelium could loosens after death, which could explain why drugs penetrate the eye much better in euthanised animals than in live ones. If the drugs prove ineffective in clinical trials, a possible refinement might come in the form of drug-coated microneedles that would penetrate the eye’s surface. Scientist Jason Jiang and colleagues at the Emory Eye Centre, Emory University, and the Georgia Institute of Technology, both in Atlanta, have been able to dramatically increase the rate of drug absorption to human cadaveric sclera and rabbit cornea in vivo using microneedles. If the implants do prove effective, Dr Murphree said that drug reservoirs implanted via laparoscopic surgery could have the potential to deliver medication to organs such as the heart and liver. Dr Csaky agreed, saying that “the sky’s the limit” if the implants work. lmurphree@chla.usc.edu karl.csaky@duke.edu 18 Episcleral implants could make eye injections obsolete Refractive Lens

Cheryl Guttman in Barcelona A NEW proprietary device for measuring tear film osmolarity (TearLab™ Osmolarity System, TearLab Corporation) appears to be a useful advance in diagnosing dry eye disease (DED) and assessing its severity, reported investigators at the XXVII Congress of the ESCRS. Jesus Fraile-Maya MD, Department of Ophthalmology, Hospital Clinico San Carlos, Madrid, Spain, reported a study comparing the osmolarity test and several other assessments conventionally used in the evaluation of DED. A continuous variable analysis of data collected in 277 subjects showed the osmolarity test was superior to the Ocular Surface Disease Index (OSDI), tear film break-up time (TBUT), meibomian gland dysfunction scoring, Schirmer test, and ocular surface staining scores. In particular, tear osmolarity was the only test that performed linearly in discriminating patients with mild to moderate DED whereas the other tests showed good utility primarily for identifying severely affected patients. “Dry eye disease is a chronic and progressive condition estimated to affect approximately 100 million people worldwide, but persons with mild to moderate disease represent more than 90 per cent of this patient population. Our study reinforces that traditional dry eye tests exhibit no correlation to disease severity in the mild to moderate range whereas osmolarity effectively characterises these patients,” said Dr Fraile-Maya. Measurement of tear osmolarity with the new system is done using a handheld instrument to obtain a 50-nl sample from the inferior tear lake near the lateral canthus. Collection of the specimen is completed in just a fraction of a second without disturbing the tear film onto a disposable lab-on-a-chip that also performs the analysis. A read-out is quickly generated by a separate desktop machine. The study reported by Dr Fraile-Maya included patients enrolled at 13 clinical sites across Europe, the US, and in Japan. DED severity for each patient was graded using a modified version of the Dry Eye WorkShop (DEWS) severity scale. Tear osmolarity and the five other parameters were equally weighted and then normalised on a scale of zero to one where zero represents normal, and mild to moderate disease was defined as a score of 0.2 to 0.4. Results of the continuous variable analysis showed roughly a linear relationship between tear film osmolarity and disease severity with much less data spread and a higher correlation value compared with any of the other dry eye assessments. Schirmer test data showed that while most patients with a severity score > 0.4 were likely to have a low score (< 10mm wetting), such a result was also obtained in a high proportion of patients in the mild to moderate cohort, and the correlation between disease severity and the Schirmer result was poor. Similarly, for TBUT, all patients with a severity score > 0.4 showed a very unstable tear film with a TBUT of about six seconds or less. However, about half of the subjects categorised in the normal to moderate cohort also had a TBUT < 6 seconds. Correlations were better between disease severity and both corneal staining and the OSDI, but again these tests had less than ideal discriminative value. Staining scores showed significant variability within the mild to moderate cohort and even among patients with more severe disease, although the latter individuals tended to exhibit large amounts of staining that contributed to a better correlation between this parameter and DED severity. The OSDI data showed that patients with mild to moderate disease were about as likely as those with worse severity to be experiencing more symptoms, reported Dr Fraile-Maya. Michael A Lemp MD, Washington, DC, is a co-author of the study and DEWS organiser. He told EuroTimes, “Of the approximately 15 tests that are traditionally used to diagnose DED, none are very good at identifying and differentiating patients with mild to moderate severity. For example, within this sub-population, a very low percentage of patients exhibit ocular surface staining, and Schirmer test results are often variable. Furthermore, Schirmer test only captures persons with DED due to aqueous deficiency, not those with evaporative disease. “Symptom severity shows poor correlation with disease severity given the tremendous psychological overlay influencing this subjective parameter, and while TBUT should be a good discriminator because tear film instability correlates well with osmolarity, obtaining valid data …depends on a high degree of detail in performance.” Dr Lemp noted that the analysis reported by Dr Fraile-Maya has practical significance for guiding management decisions considering that the DEWS panel developed recommendations for a stepwise therapeutic approach to DED based on its severity level. He also told EuroTimes that ophthalmologists could look forward to more information from additional analyses of tear film osmolarity data collected as part of this very large study, including a forthcoming diagnostic algorithm. “Based on our findings, we don’t think patients should be evaluated with osmolarity alone. However, it seems to be the single best test for identifying persons with early DED and the best tool for assessing severity of the disease. We believe the diagnosis should not be made without knowing osmolarity.” The findings from the osmolarity studies are also causing DED experts to change their perspective about the disease process, said Dr Lemp. “Previously, dry eye was considered a binary disease – either you have it or you don’t. Now we understand that, like glaucoma, DED is more of a continuum and that there is a grey zone where people begin to develop an increased probability of having DED and can be identified by changes in tear film osmolarity, reflecting their inability to maintain osmolarity homeostasis in response to environmental stresses via intrinsic compensatory mechanisms.” malemp@lempdc.com jbenitez.hcsc@salud.madrid.org 20 Jesus Fraile-Maya Tear film osmolarity excels in characterising the severity of dry eye disease Cornea Update Tear film osmolarity test being performed Tear Film Breakup Time (TBUT) Severity Analysis Courtesy of TearLab Courtesy of Jesus Fraile-Maya MD

Cheryl Guttman in Barcelona UNDERSTANDING the cellular and molecular mechanisms leading to scarring and haze after corneal injury is providing new prospects for intervention, said Gregory S Schultz PhD, at the XXVII Congress of the ESCRS. Dr Schultz, director of the Institute for Wound Research and professor of obstetrics- gynaecology and ophthalmology, University of Florida, Gainesville, presented the keynote lecture during a clinical research symposium. He described new gene-based approaches to regulating corneal wound healing in a talk he suggested could be entitled “Scar Wars”. “We still face significant challenges in controlling the wound healing response that leads to corneal haze after traumatic injury, infection and refractive surgery procedures. Currently, mitomycin-C can be used to inhibit haze formation after refractive surgery, but it has non-specific activity and the potential to cause a number of complications. It appears that better agents will be available that act by selectively targeting the genes involved in regulating fibrosis to prevent haze without presenting serious risks.” Mechanistic foundations Dr Schultz explained that when wounded by traumatic or iatrogenic insult, the cornea, like the skin, progresses through several phases of healing. Initially there is an apoptotic effect beneath the area of injury resulting in creation of an acellular zone. Within a few days, chemical mediators produced by the injured tissue induce activation and recruitment of surrounding quiescent keratocytes, which undergo significant proliferation and differentiate into activated fibroblasts and myofibroblasts. Eventually, these cells undergo another phase of apoptosis and remodelling. It is now understood that the activated keratinocytes and myofibroblasts repopulating the acellular zone are primarily responsible for light scattering, which is seen clinically as corneal haze. The molecular causes for the change in light transmission of these cells are the loss of expression of corneal crystallin proteins in the myofibroblasts and keratinocytes and increased expression of alpha-smooth muscle action (alpha-SMA) by myofibroblasts. “That is not to say that the appearance of a disordered extracellular scar matrix doesn’t contribute to light scattering, but the loss of orthogonal arrays of collagen that occurs in the scar tissue plays only a minor role,” Dr Schultz said. Transforming growth factor-beta and (TGF-beta) and connective tissue growth factor (CTGF) have been identified as the key proteins regulating the transformation of quiescent keratocytes and the expression of corneal crystallin, alpha-SMA and collagen genes. According to an emerging model derived from studies of corneal injury, TGF-beta production by epithelial cells and fibroblasts is increased in response to wounding and via auto-induction. However, CTGF appears to be the downstream mediator of many of the fibrotic effects of TGF-beta. Induced by TGF-beta, it is CTGF that directly stimulates cell proliferation, alpha-SMA expression and contraction and collagen synthesis, Dr Schultz explained (see figure). Beginning pathways to translational research Recognition of the role of TGF-beta and CTGF in the pathologic cascade leading to scarring and haze has suggested the possibility of using interventions to specifically block the activity of these proteins. So far, in both in vitro systems using cultured cells and in in vivo animal models, Dr Schultz and colleagues at the Institute for Wound Research as well as other independent investigators have used antibodies and more advanced nucleotide chemistry technologies with encouraging results. Highlighting some of this research, Dr Schultz mentioned that in a study conducted at the Institute for Wound Research using primary cultures of human corneal fibroblasts, he and his colleagues showed that both CTGF and TGF-beta induced a 3.5-fold increase in collagen synthesis. However, the effects of co-incubation with TGF-beta were blocked when either a neutralising antibody to CTGF or an antisense oligonucleotide to CTGF was added to the system. In a vehicle- controlled experiment conducted in an animal model of excimer laser ablation- induced corneal injury, Jester and colleagues showed the efficacy of treatment with an anti-TGF- beta antibody for significantly reducing corneal haze at three weeks and two months post- injury. Very recently, Dr Rajiv Mohan and colleagues reported on use of the small molecule trichostatin A as a new approach to selectively controlling the action of TGF- beta. Trichostatin A is a histone deacetylase inhibitor involved in epigenetic regulation of the transcription of various genes, including TGF-beta. It acts by preventing removal of the acetate groups from histones surrounding the gene transcription start site. Initial in vitro studies showed that trichostatin A reduced TGF-beta induced transformation of corneal fibroblasts into myofibroblasts as well as alpha-SMA mRNA expression and alpha-SMA protein synthesis. In vivo research performed in New Zealand white rabbits showed two minutes of topical trichostatin A treatment was effective in significantly reducing corneal haze after -9.0 D PRK. Positive results have also been achieved using a ribozyme targeting CTGF mRNA. In vitro studies conducted by Dr Schultz and colleagues showed this agent significantly reduced TGF-beta stimulated proliferation of human corneal fibroblasts as well as the levels of CTGF mRNA and protein produced. “The advantage of a reagent such as a ribozyme is that it is gene specific,” said Dr Schultz. He explained that ribozymes are synthetic pieces of RNA with endonuclease activity that cleave the mRNA for the gene in question. The ribozyme is specifically designed so that the flanking regions of the active side hybridise to the target mRNA nucleotide sequence. Researchers have also been working to develop transfer methods for achieving targeted delivery of gene-based interventions. Several years ago, Dr Schultz and colleagues reported their success in transducing keratocytes with a reporter gene-expressing recombinant adeno-associated virus vector applied topically underneath a LASIK flap. Subsequently they have used this platform to transfect cells with ribozymes targeting TGF- beta and CTGF. Schultzg@obgyn.ufl.edu 21 Molecular regulation of corneal scarring. Transforming growth factor beta (TGFb) is induced by corneal injury, which induces synthesis of connective tissue growth factor (CTGF). CTGF stimulates keratocyte proliferation, synthesis of collagen and transformation of fibroblasts into myofibroblasts by down regulating synthesis of corneal crystallins and up regulating synthesis of alpha smooth muscle actin (aSMA). The combination of these actions results in corneal haze and regression. Neutralising antibodies, antisense oligonucleotides, or ribozymes targeting TGFb and CTGF specifically inhibit the actions of these genes in cell cultures and reduce corneal haze and regression and animal models of corneal scarring Courtesy of Gregory S Schultz Researchers implement gene-based approaches in ‘Scar Wars’ Gregory S Schultz Cornea Update

Howard Larkin in Boston ALTHOUGH memantine failed to slow visual field loss in an international Phase III clinical trial, researchers remain confident that effective neuroprotective treatments may yet be developed for glaucoma. But it will likely be more complicated than repurposing drugs for other neurodegenerative diseases – or even simply preserving retinal ganglion cells, the loss of which is the hallmark of glaucoma. Approved for treatment of Alzheimer’s by the US FDA in 2003, memantine has been shown to slow deterioration, and improve cognition and behaviour. It is thought to do so by slowing neuron cell death by binding with N-methyl D-aspartate, or NMDA, glutamate receptors. This is thought to disrupt the prolonged influx of Ca2+ ions into neurons that cause neuronal excitotoxicity. This mechanism could be involved in the death of retinal ganglion cells in glaucoma. So in 2000, Allergan initiated a prospective, randomised, double-blind trial of memantine involving more than 2,000 glaucoma patients with well- controlled intraocular pressure testing two dose levels of memantine against placebo. But while the study showed that visual field loss progression as measured by white-on-white perimetry was significantly less in patients receiving the higher dose of memantine compared to patients receiving the low dose, the trial failed because there was no significant benefit compared to patients receiving the placebo. “When we learned last year that the trial was unsuccessful we were quite disappointed,” said Neeru Gupta MD PhD, professor of ophthalmology and vision science, and director of the Glaucoma and Nerve Protection Unit at St Michael’s Hospital, University of Toronto, Canada. Still, Dr Gupta considers the trial a breakthrough, as it was the first glaucoma clinical trial to assess the safety and efficacy of a potential neuroprectant that does not lower intraocular pressure. It generated the largest single global repository of long-term controlled visual field and other clinical data on glaucoma, which could prove invaluable to developing new neuroprotective approaches, Dr Gupta told the 2009 World Glaucoma Congress. “We may be closer to neuroprotection than we think.” She expects the data to be disclosed and analyses published over the next few months. Glaucoma is not ‘ocular Alzheimer’s’ There may be many reasons why the memantine trial did not slow visual field loss, Dr Gupta noted. Patient selection and disease stage may need to be considered. The excess glutamate model that the drug addresses may not be as central to RGC loss in humans as it is in animal models. Or the presence of excess glutamate in humans may be due to other conditions, such as diabetes mellitus, reducing the specificity of the treatment. Or the therapeutic window for administering the drug may have been missed because the test subjects all had established disease. Or other mechanisms not addressed by memantine, such as inflammatory responses, vascular ischemia or neurotrophin blockade, may be responsible for the observed progression. “We know very little regarding the fundamental biological problem,” said Dr Gupta. Glaucoma does share many features with other progressive neurodegenerative diseases, including multiple sclerosis and Parkinson’s as well as Alzheimer’s, and much has been learned by studying these diseases, noted Keith R G Martin MD, head of the Glaucoma Research Laboratory at the Cambridge University Centre for Brain Repair and consultant ophthalmologist at Addenbrooke’s Hospital, Cambridge, UK. However, each is a distinct disease process that targets particular cells in specific ways. Moreover, individual progression rates vary tremendously for all these diseases, suggesting varying degrees of susceptibility – and no one knows why. “It is overly simplistic to treat glaucoma as a form of ocular Alzheimer’s disease,” he said. Dr Martin pointed out that axonal injury is a key event in glaucoma development. “Axonal transport goes wrong early. In experimental models it has severe consequences for survival of the cell. You lose neurotrophins that are required to keep the cell alive and healthy, and lose transport of other essential molecules.” But the active mechanisms of axonal degeneration are very different from those that cause cell body death. Preserving axons will require blocking Wallerian degeneration of fibres and myelin, and preventing transport blockade. Novel approaches such as cell transplants may be possible to reduce axon loss, he said. Immune system modulation, which slows neuronal damage and even reverses dysfunction in multiple sclerosis, may help, Dr Martin added. But immune system involvement is very complex and varies by disease, and its impact on glaucoma is incompletely understood. Mitochondrial degeneration, which increases with age, is another feature common to neurodegenerative disease that may need to be addressed to contain glaucoma. Even preserving retinal ganglion cells is not as simple as it may seem. “The idea of keeping cells alive has to be looked at in terms of different kinds of life,” said Robert W Nickells PhD, professor of ophthalmology and visual sciences at the University of Wisconsin, Madison, US. Dr Nickells’ research revealed that mice lacking a gene that activates BAX, a protein that initiates irreversible pathways in apoptosis, show no RGC loss 18 months after crushing the optic nerve head, while those with normal BAX activation lose more than half of their RGC within three weeks after nerve crush. “The neuroprotection appears to be permanent,” he said. This raises the possibility of developing an agent that would prevent RGC death by interfering with BAX activation. The problem is that while RGC in the BAX-knockout mice continue to live, they cease to function normally, Dr Nickells said. “The events before BAX activation still occur. These include atrophy of RGC and global silencing of gene expression.” Both the silencing of gene expression and the activation of apoptosis appear to be epigenetic changes associated with cell death, Dr Nickells said. Interfering with either one could help preserve RGC. In fact, he has done preliminary research that suggests preventing gene silencing reduces RGC loss in wild- type mice. “Zombie” BAX-knockout cells also are no more capable of regenerating than surviving wild-type RGC. Still, there may be value in keeping the cells alive if they could be reactivated, which Dr Nickells believes may be possible. But even that wouldn’t solve the entire glaucoma puzzle. “Neuroprotection is a baby step. Every time we take a baby step, we find we have to take another. Keeping the cells alive is one thing. Getting them to turn back on is another. Getting them to regenerate is another, and getting them to reconnect with the right cells will be another. It keeps getting more complicated,” Dr Nickells said. GuptaN@smh.toronto.on.ca krgm2@cam.ac.uk nickells@wisc.edu EUROTIMES ESCRS PODCAST World Congress of Paediatric Ophthalmology and Strabismus This is a lively time in the field of paediatric ophthalmology, with important new studies in many key areas including genetics, strabismus, retina, cataract and refractive surgery. The first World Congress of Paediatric Ophthalmology and Strabismus (WCPOS) took place on September 12 & 13, 2009 during the XXVII Congress of the ESCRS in Barcelona. EuroTimes editor Sean Henahan interviewed Dr David Granet ,Professor of Paediatric Ophthalmology, UCSD, San Diego California about some of key issues addressed at the congress Listen to the interview on our podcast Eye Contact on www.eurotimes.org “Neuroprotection is a baby step. Every time we take a baby step, we find we have to take another. Keeping the cells alive is one thing. Getting them to turn back on is another” Robert W Nickells PhD Quest for neuroprotection in glaucoma moves forward despite setback Neeru Gupta Glaucoma Update 22

Howard Larkin in Boston PATIENTS with primary angle closure and primary angle closure glaucoma show higher daily fluctuation in intraocular pressure than either angle closure suspects or normal controls, according to a study reported at the 2009 World Glaucoma Congress. And while it is still not clear that high diurnal IOP fluctuation is predictive of glaucoma without elevated mean or peak IOP, it may be a risk factor to consider. “So far, studies have shown inconsistent results as to whether IOP variation constitutes a risk factor for glaucoma,” said Murat Irkec MD, professor of ophthalmology at Hacettepe University, Ankara, Turkey. He noted that a 1999 study by Bergea found both mean IOP and variation were independent predictors of glaucoma progression, and a 2000 study by Asrani and colleagues found a correlation between the magnitude of diurnal IOP fluctuation and visual field progression. However, other recent studies have questioned the link between IOP fluctuations and glaucoma progression risk in the absence of high mean or peak IOP levels, Dr Irkec noted. Still, large diurnal IOP fluctuations were found to be associated with both primary angle closure and primary angle closure glaucoma in a study presented by Rajesh S Kumar MD of the Singapore Eye Research Institute. In a prospective case-control study of 98 Asian subjects, the 32 diagnosed with PAC and the 34 with PACG had a mean fluctuation of 4 to 5 mmHg between 8am and 5pm, while primary angle suspects and normal eyes averaged about 3.7 mmHg fluctuation. PAC and PACG had twice the odds of fluctuating more than 3 mmHg compared with PACS and normal subjects. Greater diurnal IOP fluctuation also correlated with the more extensive peripheral anterior synechiae and visual field loss as measured by automated perimetry. Dr Kumar acknowledged that his use of non-contact air puff tonometry, relatively small sample size and restriction of the timing of IOP measurements to daylight hours limit the extrapolation of the study results. Nonetheless, he believes a finding of diurnal fluctuation of 4 to 5 mmHg in patients with primary angle closure or PAC glaucoma may be an indicator to treat aggressively. “Peripheral anterior synechiae and pattern standard deviation are associated with IOP fluctuation. Maybe we need to include these parameters more strongly in our clinical decision-making,” Dr Kumar said. Recent 24-hour studies also suggest that short-term IOP fluctuation may play a role in glaucomatous optic neuropathy, but it is not clear how much, Dr Irkec said. Also, there is no convenient tool for continuously monitoring IOP pressure in a typical office setting, so making a 24-hour study is not practical for routine clinical practice. However, “we need to think about current treatment standards and take into account 24-hour IOP studies to re-evaluate our treatment philosophies,” he said. One way to identify patients who are prone to large IOP swings, and the defects in aqueous outflow mechanisms that may underlie them, is the water drinking test (WDT), said Remo Susanna Jr MD, Sao Paulo, Brazil. After the patient drinks 800ml of tap water in five minutes, IOP is measured three times at 15-minute intervals. The highest IOP recorded is considered the maximum for the test. Dr Susanna noted that the WDT was devised in the 1960s as a way to diagnose glaucoma, but it isn’t reliable for that. The result of the WDT is related with glaucoma progression and the severity of damage in a given eye. “This is a stress test to see how the eye responds to pressure perturbations,” he said. In a study of contralateral eyes in 76 patients, he found that greater visual field loss over time correlated with higher peak IOPs and longer times to recover to baseline IOP after the water test. “In the worse eye, the pressure rises higher and for longer than in the better eye,” Dr Susanna said. The WDT has been used to evaluate the effectiveness of different therapies in controlling IOP spikes. One study Dr Susanna published in 2002 of patients with similar baseline IOP found that 30 medical patients saw IOP spike 3.7 mmHg on average compared with 1.4 mmHg for 30 surgical patients after the WDT. Dr Susanna echoed a 2008 editorial by Danesh-Meyer in Clinical and Experimental Ophthalmology: “The water drink test may be correlated with the severity of glaucoma and that a patient’s response to the water drink test may be predictive of visual field progression. rajesh.sasikumar@seri.com.sg mirkec@isnet.net.tr rsusanna@terra.com.br WOC®2010HonoraryPresident ProfessorDr.BruceE.Spivey,ICOPresident WOC®2010ScientificProgramCommittee Chair: ProfessorStephenJ.Ryan Co-Chairs: ProfessorBerndBertram ProfessorGabrieleE.Lang ProfessionalCongressOrganizer MonikaPorstmann PorstmannKongresseGmbH pco@woc2010.de Venue ICCBerlin www.woc2010.org www.dog.org WOC®2010ExecutiveCommittee: President ProfessorGerhardK.Lang SecretaryGeneral ProfessorAnselmKampik Treasurer ProfessorJochenKammann ProgramDirector ProfessorGabrieleE.Lang DOGManagingDirector Dr.PhilipGass WOC®2010Seeyou WorldOphthalmologyCongress®2010 Berlin,Germany XXXIIInternationalCongressofOphthalmology 108thDOGCongress 5-9June2010 AADCongress2010 3-6June2010 InternationalCouncilofOphthalmology(ICO) (Sponsor) GermanSocietyofOphthalmology(DOG) (Host) GermanAcademyofOphthalmology(AAD) (Co-Host) 23 High IOP fluctuation with angle closure glaucoma may have diagnostic value Murat IrkecRemo Susanna Glaucoma Update

Roibeard O’hEineachain in Nice A NEW agent that is expected to reduce inflammation through selective complement factor inhibition appears to be safe for intraocular use and could represent a new strategy for the treatment of neovascular age- related macular degeneration (AMD), Jordi Monés MD, Institut de la Màcula i de la Retina, Centro Médico Teknon, Barcelona, Spain, told the 9th EURETINA Congress. The new complement factor inhibitor, ARC1905 (Ophthotech), is an aptamer that selectively inhibits the C5 factor of the complement cascade. The preliminary results of a phase I study revealed no toxicity to date when administered intravitreally. The treatment used in the study combined the C5 factor inhibitor ARC1905 with the anti-VEGF agent ranibizumab, and preliminary results reveal dramatic improvement of vision in some patients, although the sample size to date is small. “These safety results to date, combined with preclinical and genetic linkage studies implicating complement-mediated inflammation in AMD, suggest that continued development of an anti-C5 strategy may hold promise for future AMD therapy,” Dr Monés added. In this phase I trial, patients are receiving three monthly intravitreal administrations of ARC1905 at one of four doses, 0.03mg, 0.3mg, 1.0mg, and 3.0mg, in combination with monthly 0.5mg dosages of ranibizumab (Lucentis®, Genentech). The inclusion criteria for the trial are subfoveal CNV due to AMD, with a total lesion size no more than five disc areas. In addition, patients must have an ETDRS visual acuity from 20/63 to 20/200, and have received no prior treatment for AMD except oral supplements of vitamins and minerals. To date, 17 patients received one dose of combination treatment (ARC1905 and ranibizumab) and have been followed for up to four weeks. There has been no evidence of acute toxicity or drug-related adverse events to date. At week four, the patients had a mean gain of 9.5 letters from baseline. Although these are early results with a limited sample size, a continuation of this trend will result in a favourable outcome compared with monotherapy ranibizumab. One eye, receiving the 0.3mg dosage, had a gain of 23 letters, while another, receiving a 1.0mg dosage had a gain of 18 letters, Dr Mones noted. There was also a decrease in the mean centre point thickness after four weeks of 104 microns, as determined by OCT. Dr Monés noted that there is a wealth of evidence that inflammation plays an important role in the pathophysiology of AMD. Research conducted over the last decade has shown AMD patients characteristically have increased monocyte activation, and increased plasma levels of homocysteine, C-reactive protein (CRP) and interleukin-6 compared to age- matched controls. Additional studies have shown that inflammation mediated by complement is important in the etiology of AMD. Polymorphism in genes coding for complement or complement regulatory proteins increase the likelihood of AMD by over seven-fold. In the eyes of patients with membrano-proliferative glomerulonephritis Type II, a complement-mediated inflammatory condition that can lead to renal failure, there are drusen that are identical to those in AMD, he said. The C5 complement factor that ARC1905 inhibits is an end product of all three of the complement pathways – the classical, the lectin, and the alternative pathways. The inhibition of C5 results in the prevention of C5a and MAC formation (membrane attack complex or C5b-C9), which give rise to inflammation and cell lysis. However, C5 inhibition does not influence the action of upstream complement factors that are important in host defence mechanisms, such as C3a and C4a, which have antimicrobial properties, and C3b, which prepares bacteria for attack by macrophages (opsonization). Studies in human donor eyes have implicated C5 and MAC in the process of drusen formation (Anderson et al, Am J Ophthalmol. 2002;134(3):411-31). In other research, C5-deficient mice exhibited inhibition of laser induced choroidal neovascularisation compared to wild type mice (p<0.001), and MAC was show to be essential for the development of this complement-mediated CNV (Bora et al. J Immunol. 2006;177(3):1872-1878). In addition, C5a up-regulates vascular endothelial growth factor, causing the creation of neovascular membranes. Dr Mones noted that although anti-VEGF therapy has introduced a new era of hope in the treatment of AMD, there is still room for improvement. For example, while the MARINA trial showed that monthly injections of ranibizumab can provide a stable and sustained gain of vision, the PIER study suggested that less frequent injections preserve but do not improve vision. “The ARC1905 aptamer binds to human C5 with high affinity and specificity, sparing the functions of C3. The preliminary phase I results show no safety concerns. Inhibition of complement activation via targeting complement factor 5 is a promising approach for therapeutic intervention in AMD”. jmones@institutmacularetina.com 24 Jordi Monés Complement factor inhibition: A potential new treatment strategy in AMD Retina Update 0HDVXUHDWWKHVSHHGRIOLJKW ’˜–Ž›¢ ȱȱşŖŖț 7KHDOOLQRQH%LRPHWHU .HUDWRPHWHU3DFK\ PHWHU3XSLOORPHWHU DQG,2/FDOFXODWRU *HWXSWRQLQHPHDVXUHPHQWV LQRQHVKRWLQFOXGLQJOHQV WKLFNQHVV $OOPHDVXUHPHQWVXVLQJ ODVHURSWLFDOWHFKQRORJ\ $OLJQRQFHJHWDOOUHVXOWV 0HDVXUHPHQWVRQ WKHYLVXDOD[LV +LJKO\UHSURGXFLEOHUHVXOWV RQDOOSDUDPHWHUV ZZZKDDJVWUHLWFRP

Dermot McGrath in Nice A FLEXIBLE dosing regimen may offer the best means of maintaining the functional and anatomical benefits of ranibizumab (Lucentis, Genentech) beyond the initial loading phase of three monthly injections in age-related macular degeneration (AMD) patients, according to a study presented at the 9th EURETINA Congress. Presenting the one-year results of the SUSTAIN study of intravitreal ranibizumab injection for exudative age- related macular degeneration, Nicole Eter MD, University of Bonn, Germany, said that the trial confirmed the earlier results of the landmark ANCHOR and MARINA trials concerning the safety and efficacy of ranibizumab treatment in patients with neovascular AMD. “The overall 12-month safety profile is consistent with that found in other pivotal phase III clinical trials with monthly and quarterly ranibizumab dosing. The visual acuity gain over the 12 months was achieved with a low average number of treatments in the maintenance phase. Moreover, the efficacy results suggest that flexible dosing based on visual acuity and OCT-guided retreatment criteria and monthly monitoring can on average sustain visual acuity and central retinal thickness values close to those achieved after three initial monthly loading phase injections,” she said. Prof Eter added that although patients sustained the visual acuity gained in the loading phase after one year, the results of the MARINA and ANCHOR trials suggest that monthly dosing may further improve patient outcomes. “These two trials demonstrated the efficacy and safety of ranibizumab when using a fixed monthly treatment regimen. Furthermore, the PIER study showed that quarterly retreatment after loading phase results in overall loss of initial gain,” she said. To build on this data, the SUSTAIN trial was designed as a multicentre open-label, single-arm, 12-month trial to further assess the safety and efficacy of ranibizumab in the AMD patient population using a guided individualised PRN dosing strategy. “The primary objective was to estimate the incidence of ocular adverse events. The secondary objectives were then to evaluate retreatment characteristics and the total number of treatments. Finally, we wanted to assess the mean change in best-corrected visual acuity from baseline to months three and 12 and the mean change in central retinal thickness (CRT) as assessed with OCT from baseline to months three and 12,” she said. The 531 ranibizumab-naïve patients enrolled in the trial had to be older than 50 years of age with active primary or recurrent choroidal neovascularisation (CNV) secondary to AMD. The total area of CNV, including both classic and occult components, had to be more than 50 per cent of the total lesion area and the total lesion size had to be less than 12 disc areas in total. Best-corrected visual acuity also had to be between 24 and 73 ETDRS letters (between 0.5 to 0.06). After receiving three consecutive monthly injections of ranibizumab 0.3mg, patients returned for monthly follow-up and received retreatment with ranibizumab 0.3mg (or 0.5mg after it became available). The criteria for retreatment included more than a five- letter loss of BCVA from the highest score of the loading phase or a greater than 100 micron increase in CRT from the lowest value of the loading phase. Out of 531 patients who began the trial, 455 patients reached the 12-month follow-up point. The average change in BCVA at the end of the loading phase was +5.8 letters, and after 12 months, the improvement was +3.6 letters from baseline. Central retinal thickness was reduced by 101 microns from baseline at the end of the loading phase, and the benefit was maintained at one year when there was a 91-microns difference from baseline. Patients received an average of 2.7 treatments from month three to month 11, and 21 per cent received no retreatment. Serious adverse events were comparable to previous pivotal clinical studies with ranibizumab, said Prof Eter. She concluded that the main findings from the study were that ranibizumab is safe and effective as a treatment against CNV secondary to AMD, and that flexible dosing based on visual acuity/OCT-guided retreatment criteria may stabilise the outcomes but does not increase BCVA above the levels achieved in the loading phase. In a separate study, researchers found that the key benefit of combination ranibizumab and photodynamic therapy (PDT) may be a reduced need for retreatments in such patients. “Our study showed that ranibizumab injection alone and ranibizumab injection in combination with standard PDT seems to be equally beneficial in preventing visual loss in wet AMD,” said Katja Hatz MD, VISTA Clinic Binningen, Switzerland. “However, the combination of ranibizumab and standard PDT seems to be advantageous because of the reduced need for retreatments, and therefore a reduced risk of complications and reduced costs,” she said. The randomised, double- masked study which was conducted at the University Eye Hospital Basel, Switzerland, included 40 patients who received three monthly intravitreal ranibizumab (0.3mg) injections combined with either standard photo-dynamic therapy or sham PDT at baseline. Thereafter, both groups received ranibizumab injections on a PRN basis if disease activity was detectable based on loss of greater than five ETDRS letters in or an increase of central retinal thickness by more than 100 microns compared to any prior visit. The results showed that BCVA increased in both groups by a similar amount, with less rapid vision gain during the first three months in the combination group. The decrease in CRT was also similar in both groups. However, the key difference was the need for retreatment between the two groups, with just 23 indications for retreatment in the combination therapy group compared to 53 in the monotherapy group between month three and 12. eter@uni-bonn.de khatz@vistaklinik.ch 25 “The overall 12-month safety profile is consistent with that found in other pivotal phase III clinical trials with monthly and quarterly ranibizumab dosing” Nicole Eter MD Flexible dosing regimen with ranibizumab may offer optimal treatment for AMD Retina Update Katja Hatz Don’t Miss EU Matters Page 45

Dermot McGrath in Nice HIGH-QUALITY images taken by a new wide field scanning laser ophthalmoscope may offer a viable alternative to digital photography in regional and national screening programmes for diabetic retinopathy, according to a number of studies presented at the 9th EURETINA Congress. “The performance of the Optos P200C (Optos, Dunfermline, Scotland) in this study was highly satisfactory,” said Ali Erginay MD, ophthalmologist at Lariboisiere Hospital in Paris, France. “With rapid, non-dilated examination of almost the entire retina it showed very good specificity and sensitivity and performs well as a screening device for diabetic retinopathy.” Dr Erginay said that the Optos scanning laser ophthalmoscope produces a 3,000 x 3,000 pixels high-resolution ultra-wide field image of up to 200-degrees or approximately 82 per cent of the retina in a single capture without pupil dilation. “The basic principle of SLO operation consists of a low powered laser beam that is scanned in two dimensions over the retina. The instrument uses the combined red and green lasers for colour imaging and both lasers follow the same optical path. Light reflected from the retina is detected and transformed into a digital computer image,” he said. Dr Erginay explained that the red and green laser wavelengths penetrate the retinal structures to different degrees, with each wavelength providing information for interpretation and diagnosis. The composite image, derived from both green and red channels, affords further analysis of the retinal image by allowing individual review of the “green only” and “red only” channel. The images generated from the green wavelength of 532 nm contain information from the sensory retina through the pigment epithelium layers of the retina, while the red channel of 633 nm contains information from the deeper structures of the retina from the pigment epithelium through to the choroid. He noted that a blue laser wavelength of 488 nm can also be included in the technology and used in the angiography mode to capture a sequence of images as fluorescein dye enters the retinal vessels. Another key distinguishing feature of the device is the directed eye steering function, allowing the physician to obtain a set of images that extend beyond the normal field of view which in some patients allows the ora serrata, which marks the extreme limit of the retina, to be visualised Dr Erginay’s study tested the performance of the Optos device against the Topcon TRC-NW6S, a fundus camera of the type frequently used to generate digital images for screening programmes, in 35 diabetic patients. Patients underwent bilateral scans, which included one wide field image without dilation captured by the Optos device, and nine field imaging after dilation by the Topcon machine. The single Optos image and the nine Topcon images were then assessed by two ophthalmologists for quality and designated as good, fair or insufficient. The far periphery was evaluated separately for Optos and graded for both diabetic retinopathy and maculopathy. A total of 68 eyes were included in the final results and the agreement for diagnosis between the two imaging devices was 100 per cent, said Dr Erginay. Both modalities detected no diabetic retinopathy in 10 eyes, minimal non- proliferative diabetic retinopathy (NPDR) in four eyes, moderate NPDR in 17 eyes, severe NPDR in 19 eyes, proliferative diabetic retinopathy in 18 eyes and diabetic maculopathy in 23 eyes. For the Topcon, posterior pole image quality was good in 53 (78 per cent) eyes and fair in 15 (22 per cent) eyes, compared to good in 64 (94 per cent) eyes and fair in four (six per cent) eyes for the Optos. Dr Erginay concluded that both methods were reliable for the detection of diabetic retinopathy and the WLSO approach merited further investigation. He noted, however, that the extreme peripheral view provided by the Optos device had no impact on the resultant retinopathy grading assigned to the eye, despite additional lesions being detected. He added that the occasional poor quality of images in the extreme superior field were frequently lid-related and could be avoided by attaching the lashes to the brow with adhesive tape. In a separate presentation, Peter J Wilson MBChB, Ninewells Hospital, Dundee, UK, stressed the importance of more effective screening for diabetic retinopathy and said that Widefield SLO (WSLO) devices such as the Optos P200C could play an important role in early diagnosis of the disease. He described a study using the Optos P200 device (an earlier version of the P200C with 2000 x 2000 pixels) in which 380 patients (759 eyes) underwent non-mydriatic imaging, followed by one- and then two- field mydriatic digital retinal photography, and then examination with slit lamp biomicroscopy. The prevalence of referable retinopathy and referable maculopathy per patient were 13.9 per cent and 10.3 per cent respectively. The technical failure rate was 6.3 per cent for dilated single-field photography, 5.8 per cent for dual-field photography, and 10.8 per cent for undilated WSLO. “While the WSLO failure rate was higher, it must be borne in mind that this figure is for undilated patients. Other studies have demonstrated much higher failure rates of up to 20 per cent without mydriasis for this kind of population, so 10.8 per cent is quite good in this context,” he said. In terms of precision, digital photography and WSLO imaging were closely matched for both specificity and sensitivity, both exceeding a sensitivity of 80 per cent for referable disease, said Dr Wilson. ali.erginay@lrb.aphp.fr pj.wilson@nhs.net 28 Ali Erginay New Ultra Widefield SLO device shows promise in detection of diabetic retinopathy Retina Update Diabetic retinopathyDiabetic retinopathy Macular Haem and Widefield HaemDiabetic haemorrhages shown in the periphery PRP and RPE Optomap® ultra widefield retinal images produced by the P200C Scanning Laser Ophthalmoscope. Courtesy of Optos plc.

Howard Larkin in Chicago WHILE European and American ophthalmic surgeons have almost universally adopted phacoemulsification and about two-thirds of both groups now use topical antibiotics for cataract surgery, the two groups continued to display divergent preferences in many areas including equipment, lenses, pharmaceuticals and surgical approaches to specific problems, according to two new surveys. Training, local regulation, market history and general economic conditions all appear to play a role in the variation, said David V Leaming, MD, of Palm Springs, California, US, who conducted the studies in 2008. The studies were based on 634 responses from members of the American Society of Cataract and Refractive Surgery (ASCRS) and 731 responses from members of the European Society of Cataract and Refractive Surgeons (ESCRS). For example, 60 per cent of the American respondents used presbyopia- correcting lenses in their practices compared with only 33 per cent of the European respondents. This may be because US law allows surgeons to bill public insurance for the cost of a standard cataract procedure with the patient picking up only the added cost of the premium lens and fitting services; in most European countries public insurance will not cover any part of a premium lens procedure, leaving the patient to pay the entire cost of both the procedure and the lens out of their own pocket, Dr Leaming explained. Nearly 80 per cent of European respondents also said they would not implant a presbyopia-correcting lens in a patient with previous refractive surgery. “There are more problems with the power calculations and this group of patients tend to have higher expectations in their results. The same question wasn’t asked in the ASCRS survey but I’m fairly certain similar results would be found,” Dr Leaming said. This issue may limit the pool of potential premium IOL candidates as many patients who have previously had refractive surgery would be more likely to be open to a premium lens. US surgeons also appeared more likely to take steps to correct astigmatism in cataract surgery, with 60 per cent using toric lenses compared with 44 per cent of European respondents; and 52 per cent of US surgeons using limbal relaxing incisions compared with 36 per cent in Europe. “LRIs have been advocated for years as the trend toward refractive cataract surgery progresses. I think toric IOLs are an improvement in predictability with positive financial incentives as well. I’m sure toric IOLs will increase in use in the EU but will be limited if the physician has to pay extra for that technology and cannot balance bill the patient,” Dr Leaming said. Lens availability influences practice choices However, European respondents were more likely to report offering refractive lens exchange, with 44 per cent doing so compared with 24 per cent in the US. Europeans were also more likely to use phakic lenses, with 36 per cent compared with 12 per cent in the US. The greater availability of approved phakic lenses in Europe may account for this, Dr Leaming noted, though 37 per cent of US surgeons reported they plan to start using phakic lenses. Liability concerns may also inhibit RLE in the US, he added. European surgeons were also more likely to embrace microincision cataract surgery, with 4.2 per cent routinely using a sub-2mm incision compared with 1.5 per cent in the US; 27 per cent using coaxial microincision equipment versus 19 per cent in the US; and nine per cent using bimanual microincision equipment compared with five per cent in the US. Here again, more thin lenses that can be used with sub- 2mm incisions are available in Europe. Alcon Infiniti with OZil, Bausch & Lomb’s Millennium and Abbott Medical Optics’ WhiteStar phaco machines finished 1-2-3 in both surveys. US intracameral antibiotic use still trails In the wake of the landmark ESCRS study demonstrating that intracameral cefuroxime reduces the risk of endophthalmitis, 57 per cent of European respondents reported using intracameral antibiotics, up from 52 per cent in 2007 and more than double the rate reported in 2004. Meanwhile, US use of intracameral antibiotics held steady at 10 per cent last year amid safety concerns about the lack of an ophthalmic preparation of cefuroxime and continued faith in the superior efficacy of the fourth generation fluoroquinolones that are available for topical use in the US but not in Europe. However, 26 per cent of US surgeons did report using antibiotics in irrigant solutions, compared with 20 per cent in Europe, though the evidence of the efficacy of this practice is not as strong as that for intracameral injections. European surgeons were also much more likely to perform bilateral cataract surgery on the same day, though rates varied widely by country. Only 0.3 per cent of US surgeons reported doing bilateral procedures compared with 10 per cent of European respondents, with 65 per cent doing so in Finland and 26 per cent in Sweden. US surgeons were also more likely to use non-steroidal anti-inflammatory drugs before surgery, with 79 per cent doing so compared with 36 per cent in Europe. Of those using NSAIDs, 66 per cent of US surgeons started treatment three days before surgery compared with 28 per cent in Europe. Hydrophobic acrylic lenses remained the overwhelming favourite on both sides of the Atlantic, with 80 per cent of US surgeons and 77 per cent of European surgeons preferring them. Alcon’s AcrySof Aspheric was the top hydrophobic acrylic lens choice in both surveys. Alcon’s ReSTOR was the top presbyopia- correcting choice in both surveys, followed by Bausch & Lomb’s Crystalens in the US, and Carl Zeiss Meditec’s AcriLisa and AcriLisa Toric in Europe. European surgeons were more likely than their US counterparts to do LASIK, LASEK and PRK, but US surgeons who do laser refractive surgery were more likely to use wavefront guided procedures, with 81 per cent doing so compared with 61 per cent in Europe. Femtosecond laser flap cutters continue to gain popularity, with 33 per cent using them in the US and 59 per cent wanting to acquire the technology. The ASCRS survey was sent to 4,993 recipients for a 13 per cent response rate while the ESCRS survey went to 3,350 members and generated a 22 per cent response. Alcon, AMO and Bausch & Lomb were major sponsors of both surveys; Ophtec was a minor sponsor of the ESCRS study. Eyeopr8@aol.com. 29 Annual surveys show European and American practice differences persist Ocular Update David V Leaming 0LQLPDOVL]Hh $WWUDFWLYHSULFHh 0XOWLSOHVOLWODPShDGDSWHUV ,QGLUHFWRSKWKDOPRVFRSHh 6L]H[[PPh (QGRSUREHVJh 7KHQPJUHHQhODVHU 0DGHLQ*(50$1< )RQ )D[ LQIR#DUFODVHUGH ZZZDUFODVHUGH &/$66,& /CUGT3JQVQEQCIWNCVQT

THE online European Registry of Quality Outcomes for Cataract & Refractive Surgery (EUREQUO) has successfully begun collecting data from centres in Scandinavia, the Netherlands and Spain. The pilot project is testing software user interfaces, integration with national registries and technical support systems to work out any remaining kinks in advance of EUREQUO’s roll-out across Europe in 2010. “The ESCRS believes firmly that a continuing audit of surgical outcomes is necessary to ensure the best care of our patients,” ESCRS president Paul Rosen FRCS, FRCOphth said of the EUREQUO registry in his welcoming address to the XXVII Congress of the ESCRS in Barcelona. Because of its important role in improving patient well-being it has attracted substantial matching funds from the EU as well as partnerships with 12 European countries to develop national visual outcomes registries for cataract and refractive surgery, he noted. “The data collection will involve individual practitioners, small clinics, large hospitals and university institutions. By making comprehensive data available for comparison of visual outcomes, EUREQUO aims to build up a network to facilitate the exchange of best practices,” Dr Rosen added. While EUREQUO establishes standards for data collection for all participants, and will be available via web browser from anywhere, individual national societies will retain authority to determine data collection and audit standards within each country. National registries in each country will also provide first-line technical support for individual users. All data will be anonymous, allowing only surgeons submitting data to have access to their own data. Individual results can then be compared with aggregate results for similar procedures overall, by country or region, or by patient characteristics, including demographics, preoperative visual acuity and co-morbidities. As of mid-September, EUREQUO had integrated existing data from the Swedish National Cataract Registry and work had begun integrating the existing Netherlands database. The system is expected to have about 580,000 patient data sets available for comparison when it goes live across the continent next year, according to Rainer Waedlich, chairman of ifa systems AG, and integration AG, Germany. The firms, which have more than 20 years’ experience developing ophthalmology IT systems, helped develop the EUREQUO software and are maintaining the central database. Practical benefits EUREQUO participation will provide surgeons with many benefits, said Peter Barry MD, Dublin, Ireland. First and foremost, it allows surgeons to assess their own work. “It gives you self-respect. You always know your results for your own satisfaction,” he said. Knowing your results not only helps you improve, it helps you explain your work to patients, Dr Barry added. “To be able to precisely identify a probable outcome is an important element in the informed consent process.” Participating in an audit system also may help defend malpractice suits, Dr Barry added. You will be able to show your outcomes, and also that you have diligently adhered to established care standards and made continuous efforts to improve your practice. “You also will be making a bona fide contribution to developing evidence- based guidelines,” Dr Barry said. The scale of the EUREQUO database will make it possible to develop guidelines not only for common outcomes and complications, but also for events and conditions that are too rare to be studied in any one clinic or hospital. Dr Barry believes that participating in an outcomes database is becoming a practical necessity. Hospitals and clinics want to see your outcomes. “They will not listen to you anymore unless you provide evidence of the quality of your work. If you can do it you will win contracts over competitors.” Insurers and state-run health plans also want data. Using electronic data collection has become a requirement to get paid in The Netherlands, said Ype Henry MD, Amsterdam. Dr Barry added that by participating in EUREQUO “you will be part of the future. It is inevitable that you must be able to record results. You must be able to show them and you must be able to show evidence of audit. If you don’t, you will be effectively out of business”. Accessing EUREQUO In designing EUREQUO, surgeons and IT specialists drew on long experience with national registries, as well as the international European Cataract Outcomes Study (ECOS) conducted since 1995, and the Refractive Surgery Outcomes Information System established in 2006, said Mats Lundström MD, Karlskrona, Sweden, who oversees the Swedish National Cataract Registry and ECOS. He found that ease of use is essential to ensure participation. A national registry will be set up in each country. These registries will be accessible over the Internet, and will be the primary contact point for surgeons in each participating country. Data from each registry will be forwarded to EUREQUO. Surgeons will have access to aggregated data from their own country as well as the entire database through their national registry interface. National registries will also provide clinical and technical support, backed up by Prof Lundström’s Eyenet Sweden for clinical and data collection issues, and ifa systems AG for technical problems. Data collection has been made as simple as possible. Patient information is entered on a one-page web form, which includes pull-down menus for refractive values and other data. “It’s just click-click-click,” said Dr Henry, who demonstrated how the existing Netherlands online national registry form has been integrated into EUREQUO. Coordinating through the national registries will help ensure that forms and support are available in the local language, and meet local data collection needs. To avoid the need for double data entry, EUREQUO provides interfaces that centres can use to export survey data directly from their electronic records systems, Mr Waedlich said. The export- import system supports many standard data formats, including DICOM and HL7, which are commonly used in hospital and large clinic data systems. Technical support will be available to help individual centres develop export routines to minimise data entry burdens. In addition to collecting live data from the three pilot countries, EUREQUO is now testing the functionality of the system in all participating countries, Prof Lundström said. “We need to see what happens when users start putting in data. There are always some surprises.” Prof Lundström expects the roll-out to begin early next year, followed by an evaluation. phrosen@rocketmail.com rainer.waedlich@ifasystems.de peterbarryfrcs@eircom.net mats.lundstrom@ltblekinge.se EUREQUO registry Courtesy of ifa systems AG 30 “The ESCRS believes firmly that a continuing audit of surgical outcomes is necessary to ensure the best care of our patients” ESCRS president Paul Rosen FRCS Paul RosenPeter Barry EUREQUO quality registry set for 2010 launch across Europe Ocular Update Mats Lundström

Dermot McGrath in Manama OPHTHALMOLOGISTS in the Middle East and Africa region are facing an uphill battle in preserving the sight of millions of patients presenting with diabetes-related ocular disease. While the prevalence of Type 2 diabetes has increased all over the world in recent years, nowhere has the rise been more dramatic and more keenly felt than in the Middle East and North Africa. The number of adults with diabetes in the Middle East and North Africa regions is expected to nearly double over the next two decades from 25 million to 45 million, according to a recent report from the International Diabetes Federation. Even more alarming, the number of people with impaired glucose tolerance (IGT), or pre-diabetes, will also rise to 39 million from the current level of 22 million unless governments and health authorities take concerted action to reverse the trend. “The diabetes time bomb has been ticking for 50 years, and it’s been getting louder,” warned Martin Silink AM, MD, FRACP, of the International Diabetes Federation. “Despite the warning, successive generations of world leaders have largely ignored the threat. Diabetes has now exploded with the force felt greatest in the Middle East, India, China and the US,” he said. Of the top 10 countries with the highest prevalence of diabetes, five of them are located in the Gulf region. In 2007, the diabetes prevalence rate in Qatar was 15.2 per cent, 15.2 per cent in Bahrain, 19.5 per cent in the United Arab Emirates, 16.7 per cent in Saudi Arabia, 14.4 per cent in Kuwait and 13.1 per cent in Oman. By 2025, these rates will rise respectively to 16.9 per cent, 17 per cent, 21.9 per cent, 18.4 per cent, 16.4 per cent and 14.7 per cent. Abdulaziz AlRajhi MD, president of the Middle East African Council of Ophthalmology (MEACO), said that his organisation is very aware of the challenges posed by the diabetes epidemic and he urged health authorities in the region to play their part in helping the medical community to deal effectively with the crisis. “Diabetes is certainly an issue of growing concern. Diabetic retinopathy is an important cause of blindness. According to WHO reports, after 15 years with diabetes approximately two per cent of affected individuals become blind and 10 per cent develop severe visual impairment. There are seven countries from the MEACO region – five of which are from the Gulf region – that are among the 10 most affected countries globally in terms of diabetes. So we definitely need to work on this and make plans to deal with this crisis,” he said. Dr AlRajhi noted that screening for diabetic retinopathy is one of the most cost effective interventions in medicine. The number of ophthalmologists being trained every year in certain countries is nowhere close to the number that is needed to be at least self- sufficient in the future to serve the ocular needs of their populations. “We have to let the decision-makers be aware that this problem exists and to play our part in advocating an increase in education and training for the future. While it may seem initially a major investment for any government, the long-term rewards are cost-effective and more than justify the investment,” he said. And in some quarters at least, it seems that the message is starting to resonate at the highest levels of government. The Eastern Mediterranean Region has already developed its guidelines for the management of diabetic retinopathy. These were based mainly on guidelines that were developed earlier by the Gulf Countries. Qatar, for example, has recently established a medical centre of excellence to tackle the epidemic of diabetes and obesity among its population. The government is also actively encouraging research programmes to explore new treatment approaches to diabetes and to understand more about the genetic underpinnings of the disease among natives of the Arabian Gulf. A key part of the Qatari government’s strategy has been to raise public awareness of the importance of a healthy lifestyle. As many as 12 per cent of adult Qataris responding to the 2008 Qatar World Health Survey suffered from diabetes, compared to eight per cent in a similar survey in 1998. Some 30 per cent of respondents were classified as pre-diabetic. Researchers say that a complex interplay of genetic, social and environmental factors is driving the global explosion in Type 2 diabetes. Prof Silink told EuroTimes that lifestyle changes allied to genetic predisposition among Arabic populations are largely responsible for the explosion in diabetes in the Gulf region. “The causes are predominantly lifestyle related, such as decreased physical activity and nutritional changes associated with rapid development. In addition, the Arabic races share an increased genetic risk for diabetes that is shared by virtually all non-Europid ethnic groups. There is good evidence that the risk for diabetes and cardiovascular disease starts increasing at a lower body mass index (BMI) in various races. For Europids the risk starts to rise after a BMI of 25. In Asia, the risk increases after a BMI of 22,” he said. Prof Silink said that effective measures to counteract the rise in diabetes in the short term include increased physical activity and weight loss for certain patients. “We need to redesign how well we eat, drink, work, travel, use our leisure time, involve ourselves in sport, design our cities, translate health knowledge into healthy behaviour and accept tobacco control. For those who already have diabetes, the outcomes depends on how well blood glucose, blood pressure and cholesterol are controlled,” he said. Prof Silink added that it has taken many years to develop the robust data on diabetes and other NCDs. Another problem was that the United Nations Millennium Development Goals (MDGs) completely ignored the NCDs and thereby determined the health priorities for donor countries and through this the health priorities of the recipient (developing) countries, he concluded. Recognising the impact of diabetes in the region, IDF will hold its 21st World Diabetes Congress in Dubai, United Arab Emirates in 2011. MartinS@chw.edu.au dralrajhi@emr-iapb.org 31 MEACO region tries to stem the rising diabetes tide Ocular Update Abdulaziz AlRajhi European Registry of Quality Outcomes for Cataract & Refractive SurgeryEUREQUO What is EUREQUO? Improve treatment and standards of care for cataract and refractive surgery Develop evidence-based guidelines for cataract and refractive surgery across Europe Make significant impact on the exchange of best practice between practitioners in relation to patient safety 1 2 3 The project aims to: EUREQUO is a European Quality Registry for visual outcomes of cataract and refractive surgery Join the network EUREQUO gives a unique opportunity to monitor and compare results Quality registries create a sufficient basis for studying rare diseases, treatments and complications Collecting data will support you to make an audit report The collection of your data will facilitate the analysis of surgical outcomes and the development of evidence-based European Quality Guidelines with the kind contribution of See www.eurequo.org for more information

Feature T he 14th ESCRS Winter Meeting in Budapest promises to add its mark to the rich history of ophthalmology in Hungary. Of course, many of the men and women who have helped to develop Hungary’s ophthalmological tradition will be in Budapest between February 12 and 14 of next year for the historic meeting. Those ophthalmologists and many other meeting attendees will surely use the occasion to recall the contributions of the country’s pioneers in the specialty. One of those whose contributions will most surely come to mind is Aladár Kettesy (1893-1983), who published Eingriffe am Auge in 1945. The book was used as a text for eye surgery in Germany for more than 30 years and even translated into Spanish in 1947. That book is just part of the legacy of Kettesy; to this day, ophthalmologists inside and outside of Hungary still revere his contributions to ophthalmology. In 1911, Kettesy enrolled at the Medical Faculty of the Pázmány Péter Catholic University, one of Hungary’s oldest and most prestigious institutions of higher education. Three years later, in 1914, he joined the army, and during World War I he worked for four years as a medical officer. In November 1919, he was appointed vice-physician at the State Eye Hospital in Budapest. He moved to the Eye Clinic of Debrecen in 1921, where he was to remain for the next 45 years. In 1926, Kettesy became director of the clinic and in 1929 he was promoted to the post of “ordinaries” professor. Kettesy also had many interests outside ophthalmology. He was a keen game hunter, yachtsman and fisherman. He was also a prolific writer, writing not only about his own clinical activities but of the wider responsibilities of the doctor. Writing in the Magazine of Doctors and Pharmacists, he discussed “The deep causes of the crisis in the doctor’s status” in an article published in 1936. “Medical science, this big hulking thing, has swallowed the belief as well: the public these days doesn’t trust the doctor, but medical science,” he wrote. “Just because of this I would not believe in restoring the institutions of the family doctor, even if some attempt has been made recently. With the aid of a poetic picture I could say, that the prestige of the general practitioner – the one and only proper and desirable medical character – was hit by fast train of scientific progress.” Before World War II, Kettesy went on a number of overseas study trips and took part in many international congresses. The outbreak of the war was to have a profound impact not only on his professional career but also on his political beliefs. Kettesy spent the last days of World War II in a cellar in Buda where he treated wounded Hungarians, Germans and Russians. When the war ended, he returned to his clinic in Debrecen, but it had been completely gutted. Because all the textbooks in the university had been destroyed, one of Kettesy’s first tasks was to write a new text that became the official university handbook until 1962. Kettesy, embracing the changes that followed the war, also continued to develop his personal political philosophy. His biographer, Prof Béla Alberth, wrote: “In his private practice, where I deputised for him, one examination cost 100Ft (forints), or, later, 200 Ft. He taught me that if I asked for 100Ft, and the patient had only 50Ft, nothing should be accepted. For if someone comes to the professor to be examined and he hasn’t got 100Ft, that person is surely a very desperate and poor man, who must be helped. “He also said that, compared to the ophthalmologist, the surgeon’s and the internist’s situation was easier since if their knowledge failed, the patient usually died and never returned to see the doctor. Ophthalmology’s failure is when a patient goes blind. But the blind patient comes back for years to the doctor, and always reminds you that no matter how much you know, you do not know enough. You must not accept any money from an incurable blind patient, since your ignorance would be rewarded by doing this, and that is immoral. But if you can help, that should be paid for. Only knowledge, not ignorance, should be rewarded.” In the summer of 1956, after 10 years of complete isolation after the war, Kettesy travelled to the East German town of Greifswald for the first symposium on keratoplasty. There, he left a lasting impression among his fellow ophthalmologists, according to Grabner Gunther. “All who met Kettesy, found him unforgettable,” Gunther wrote. “He had the talent, when making a toast, to bring up often surprising technical details and to give a speech that touched the hearts of all his listeners. He had a scintillating wit, was agreeable as a colleague, modest in professional matters, always ready to assist friends and patients, lacking in envy and always ready to acknowledge the achievements of others. We came to know his expansive movements, his quick eye and sharp sense of humour. Kettesy – an example to us all!” Despite the constraints of Communist rule of Hungary and the rest of Eastern Europe, Kettesy continued his world- leading research, which culminated in 1956 with his groundbreaking paper on photocoagulation. Kettesy also left a lasting legacy from his ongoing clinical experience, too. Magdolna Zajácz noted that Kettesy had observed that by putting a simple ball of cotton to the eye and pressing it with a rubber belt, the eye became softer and every kind of surgery involving the opening of the eye could be performed more safely. “Today, many precise factory-produced oculopressors can be bought, but the idea of oculopression is the immortal invention of Prof Kettesy,” Zajácz wrote. Kettesy also played his part outside of medicine, as a participant in the great Hungarian Revolution of 1956. Although it appeared as if the Hungarians had won independence in the early days of that autumn, Soviet tanks entered the country on November 4 and squashed the hopes and dreams of a generation as more than 2,500 Hungarians died and more than 200,000 fled. On November 4, Kettesy had broadcast a communiqué on Debrecen radio in English, German and French asking the outside world for help against the Russian invaders. The following day he was arrested and spent three days in police lock-up. It was suggested to him that as an eminent physician, he should not interfere in politics and should concentrate only on ophthalmology. Kettesy gave this undertaking and was released for prison. As he approached the end of an eventful life, he won international recognition. The German Ophthalmological Society made him an honorary member, and the German Academy of Sciences Leopoldina elected him as a full member. After his retirement in 1969, he continued to write; his last paper was published in 1980, when Kettesy was 87 years old. He died in his sleep, aged 90, on the evening of 30 January 1983. This article can offer only a brief account of Kettesy’s achievements but Ophthalmology in Hungary by Magdolna Zajácz offers an excellent introduction to the life and works of Kettesy. The book was written for the 11th Congress of the European Society of Ophthalmology held in Budapest in 1997. The chapter on Kettesy is based on the personal recollections of Dr Zajácz, and his successor in the chair at Debrecen, Prof Béla Alberth. Prof Alberth is the author of The life and the work of Dr Aladár Kettesy. I am very grateful to Prof Andras Berta MD, president of the Hungarian Ophthalmological Society, for giving me a copy of the book and for his assistance in writing this article. 32 Eye on History Pioneering Hungarian doctor’s vision has inspired generations of ophthalmologistsby Colin Kerr Aladár Kettesy pictured with some of his writings

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

35 Instant Clinical Diagnosis in Ophthalmology, Strabismus Series Editors: Ashok Garg and Emanuel Rosen Editors: Eric R Crouch and Ewa Oleszczynska Prost Jaypee Brothers Medical Publishers, 2009 V ision does not happen in one place, but in many. It is not one process, but many. One of the most important, and often forgotten, aspects of vision is that it is binocular. All the marvellous work of the lens, retina, optic nerve and other ocular apparatus does not occur in isolation, but is a duet with the “other eye”. Many readers will know from personal as well as clinical experience that this duet is not always one of perfect harmony. One of my outstanding childhood memories is having an eye patch to correct for amblyopia, or as it was somewhat pejoratively – and inaccurately – called, “lazy eye.” I well remember the distinctive texture of the patches, with their oddly fragile yet adherent adhesive, and their faint odour. I also remember walking in a park and a younger child saying, in all innocence, “look at the boy with the broken eye.” Strabismus is a clinical condition in which the eyes do not align correctly together. It can be a disorder of higher centres, with the brain not coordinating the eyes, or a disorder of ocular muscles, leading to dysfunction of the usual direction and power of the muscles. In some way the focus, therefore, is less on the eye itself as in other conditions and more on the muscles and higher centres. In this volume, Dr Crouch and Dr Post have edited a comprehensive approach to strabismus in two major sections. The first section begins with a consideration of the factors that go to make binocular vision, and the tests that can be used to assess it. Such venerable and familiar tests as the Titmus stereo test (well I remember trying to grab the wings of the three dimensional fly) are discussed. I was somewhat disappointed to learn that these tests, a nostalgic feature of my childhood visits to an ophthalmologist, can in fact be second guessed by patients without stereopsis by using monocular cues. We then have a long, thorough chapter by Drs Amar Agarwal and Ashok Garg on paediatric strabismus examination. This covers history, clinical examination, motor tests and sensory tests. The authors give a schematic approach to this area and useful flowchart-type diagrams of how to perform a cover test. Adaptations in strabismus are dealt with in two chapters – one by Drs Agarwal and Garg again, as part of a general chapter on signs and symptoms in strabismus, the other by Drs Jawahar Lal Goyal and Navjot Kaur on sensory adaptations. My old friend amblyopia appears here. One of the volume’s co-editors, Dr Ewa Oleszczynska Prost, contributes the following three chapters on esodeviations, exodeviations, and amblyopia. The rest of the first section gives a very thorough account of other clinical presentations and of non-surgical approaches. The second section, which is briefer than the first, is on strabismus surgery and recent advances. These chapters are exciting and interesting, as they open new perspectives on the condition. For instance, Dr Jorge L Alio and Dr Carlos Laria discuss a video-oculographic perspective on strabismology, which reviews the ocular musculature, movements, and ocular motility laws before going on to discuss the application of their own technique. This is another in the “Instant Clinical Diagnosis in Ophthalmology” series and is a worthy addition to the series. It is a comprehensive textbook, and one which is well designed and illustrated. Most of the chapters are divided into easily navigable sections, and tables and schematic diagrams abound. In some ways this book goes beyond the simple vade-mecum concept which seems to be the rationale for the Instant Clinical Diagnosis series, and gives a much more comprehensive approach. One feature which perhaps could enhance the book would be a more inclusive, and book-specific, foreword, with perhaps an “executive summary” of each chapter. There is a lot of information on many innovative areas and some of this information is rather buried in the text. The series seems to have a generic foreword (beginning each time with the words “in modern day busy and fast life, ophthal- mologists are glued to their clinical and surgical practice and have little time to read large volume books”) with some slight changes. A foreword that summarised the important points made in each individual chapter would allow the reader to quickly get a sense of what information is where. As outlined previously in this column, while the Instant Clinical Diagnosis series is impressive, it is not quite the series of easy-to-use portable volumes that the stated aims of the editors would suggest. This is actually the most impressive of the Instant Clinical Diagnosis books that I have reviewed, to the extent that I would suggest that it could be promoted as a textbook in its own right. Feature In Your Good Books Strabismus: where treatment demands thinking outside the boxby Seamus Sweeney            ‹$QJLRWHFK3KDUPDFHXWLFDOV,QF ‹6XUJLFDO6SHFLDOWLHV&RUSRUDWLRQ $OOULJKWVUHVHUYHG23*30 $QJLRWHFK'HQQLV'ULYH5HDGLQJ3$       \ [ The IQ Geometry™ Knife’s innovative design performs beyond standard knives: Hollowed bevel design minimizes tissue contact, resulting in a 37% reduction in penetration force* 40+% thinner than standard blades results in a superior wound architecture* Sharpoint™ Infinite Edge™ proprietary finishing technology for consistent sharpness *Data on file. 999T*#421+06T%1/ 106#%675 (14#241&7%6'8#.7#6+10#6 *#421+06u#0)+1T%1/ 14KGFJFJgJHJJ $1*B,4JHRB(XUR7LPHVB-XO$XJLQGG30

Feature I n medical circles, entrepreneurs sometimes get a bad rap. Look no further than Jeffrey Skilling, says Keith Willey BSc, MBA, of London Business School. As CEO of Enron, Mr Skilling’s great entrepreneurial achievement turned out to be one of the largest corporate frauds in history. “Harvard Business School had scheduled Jeff to address the graduating class that year, but he went to jail instead,” Mr Willey told attendees at the inaugural EuroTimes Entrepreneurial Masterclass for Ophthalmologists, part of the Practice Development Workshops held at the XXVII Congress of the ESCRS in Barcelona, Spain. So why would a surgeon want to take up a mantle long tied to hucksters and snake oil salesmen? Because that’s really not what entrepreneurship is, Mr Willey says. There are many positive models of entrepreneurs, including Bill Gates and Sir Richard Branson. Indeed, entrepreneurs are now widely viewed as the salvation of blighted economies. “Anyone can be an entrepreneur; you don’t have to be like these guys,” says Mr Willey. He points out that, in general, there are two kinds of an entrepreneur – the kind who looks for business opportunities to flip for a quick profit, and the kind who transforms an idea or a passion into a successful business. Generally speaking professionals, including surgeons, tend to fall into the second category. “Entrepreneurs are seldom driven solely by money,” Mr Willey says. To illustrate, he displayed results of a survey he conducted in preparing for the Masterclass, which asked participants about their practice goals. While growing sales was a top concern for most attendees, so were maintaining high care standards, developing the capacity to negotiate with insurers and health ministries, and getting away from 16-hour workdays. Or, as one surgeon in the class put it: “Losing €100,000 bothers me, but not as much as a complication in cataract surgery.” To which another added: “You can be a superb surgeon and keep complication rates down and still be an entrepreneur, but you cannot be so financially driven that you cut corners. If you go there, you are finished.” Clearly, for a surgical practice, clinical excellence is a necessary condition for being in business, Mr Willey notes. It is also necessary, but not sufficient, to build a practice that meets its owners’ professional, business and personal goals, he adds. Whether these goals include making more money, serving more patients, doing more research or just keeping up with new technical and financial requirements, achieving them requires surgeons to develop skills beyond wielding instruments. And that is where entrepreneurship comes in. Getting ahead in a changing world A common academic definition of entrepreneurship is “the process by which individuals pursue opportunities without regard to resources they currently control”, Mr Willey offers. In the context of a surgical practice, this means developing a vision and a plan for your organisation that leverages your business opportunities without sacrificing clinical excellence. Balancing these concerns often leads surgeons to form groups, Mr Willey says. This is the first step toward being an entrepreneur in that it allows sharing of business office, equipment and other expenses that can make individual practices more profitable while each member retains control over their own practice. “Being configured the way most small practices are offers a relatively stable existence; a sort of local monopoly and a comfortable place to practice the profession for which you’ve been trained.” However, such loosely structured practices are limited by the individual goals of each member. How much money do I want to make? What kind of procedures do I want to perform? What kind of patients shall I serve? How much time do I want to spend at work and with my family? How long do I want to practice before I retire? Differing answers can limit a group’s potential, Mr Willey observes. “You are sleeping in the same bed, but dreaming different dreams.” On top of that are increased external demands. “Our once-reliable state or insurance funded systems are squeezing down on costs and the clients are demanding innovation and value for money. These are forces hard to ignore and unless a surgical practice adopts some of the approaches of a business-led operation then they are likely to fade away.” Applying business approaches to surgical practice is not all that different from the scientific method, Mr Willey notes. “As a surgeon you would not take great risks with a patient’s health but would be careful in weighing up a new routine, trialling it and finding ways to test it in a small scale, measuring outcomes as you go. That approach is to be recommended in developing a business too. Entrepreneurs are not bet-the-farm types. One colleague has described their mantra as ‘heads I win, tales I don’t lose much.’” In other words, entrepreneurs are – or should be – data-driven. So the first step of developing a practice is to get the facts. What are the financial results of our operation? Who are our customers? What do they want? Where do they come from? Just what are the opportunities? “A business person undertakes research. If this is a first- time exercise, usually the important trends are obvious and the right response equally easy to divine. Let’s say one type of laser routine is giving way to a new fashionable one asked for by patients. Should we watch business decline or take on board the new service? Easy decision!” A quick success helps establish the value of data analysis and business planning, and lays the groundwork for building a coherent team that can realise further gains, Mr Willey points out. “Getting this kind of thinking shared and embedded with colleagues in the practice is a difficult task so best to tackle it at these early stages when some good results can be achieved quickly.” In the process, surgeon colleagues favouring further development will reveal themselves. It is in the collaborative work of such a team that entrepreneurial spirit flourishes, Mr Willey adds. “Perhaps the most powerful tool needed to change to a more entrepreneurial approach is to have a plan: one that is ‘owned’ by the core team and that is used regularly to compare progress. With a planning and review framework in place the development of the practice can be managed effectively, opportunities can be pursued without recklessness or random behaviour and feedback can be collected to improve the results.” In a medical context, this is what constitutes entrepreneurship. kwilley@london.edu EuroTimes will be hosting a Practice Development Workshop at the 14th ESCRS Winter Meeting in the Corinthia Grand Hotel Royal in Budapest on Friday February 12, from 14.15-16.45. The workshop will focus on ‘Advanced Technology in Ophthalmological Practices in the New European Environment.” To register go to www.escrs.org. For further information see www.eurotimes.org. 36 “Perhaps the most powerful tool needed to change to a more entrepreneurial approach is to have a plan: one that is ‘owned’ by the core team and that is used regularly to compare progress” Practice Development Surgeon or entrepreneur? It’s possible – maybe even necessary – to be bothby Howard Larkin Keith Willey, associate professor, London Business School, addressing the one-day Masterclass for Ophthalmological Entrepreneurs in Barcelona

How to incorporate premium technology into your practice in the new European environment PRACTICEDEVELOPMENTWORKSHOP 14.15 Introduction and welcome Paul McGinn, Barrister at law 14.20 The rationale for creation of a premium practice Erik Mertens, medical director, Medipolis 14.35 The rationale for creation of a premium practice Sheraz Daya, medical director, Centre for Sight, Corneo Plastic Unit & Eyebank, Queen Victoria Hospital, East Grinstead, UK 14.50 Eye Microsurgery Clinics Network: The Russian Experience Boris Malyugin, Deputy Director General, S. Fyodorov Eye Microsurgery Complex State Institution, Moscow, Russia 15.05 Understanding the business side of premium technology Trudy Larkins, Global marketing director for LenSx Laser 15.20 Strategies for communicating and marketing premium technologies in your practice Kris Morrill, KAM Communications 15.35 The ethical pros and cons of premium technology in the European healthcare system Paul McGinn, Barrister at law 16.05 The importance of patient-focused care Oliver Findl, Moorfields Eye Hospital NHS Foundation Trust, London, UK 16.20 Questions and Answers 16.45 Conclusion 14TH ESCRS WINTER MEETINg Budapest, Hungary CorintHia grand Hotel royal FRIDAy 12 FEbRuARy 2010 14.15 PM – 16.45 PM to register visit: www.escrs.org Facilitator and MC: Paul McGinn, EuroTimes Editor and Barrister at law Moderators: Sheraz Daya / Paul Rosen Schedule: EUROTIMES ESCRS ™ A EUROPEAN OUTLOOK ON THE WORLD OF OPHTHALMOLOGY

Feature I t’s hard to talk about Rayner Intraocular Lenses Ltd without bringing up Sir Harold Ridley and the firm’s pivotal role in originating and perfecting the IOL concept. It was 60 years ago this month since Ridley performed the first IOL operation. The posterior chamber lens he implanted was designed with assistance from John Pike of the Rayner Company, and manufactured by Rayner, then an optician and producer of precision optical instruments. “We are the only company that has been making IOLs for 60 years, and we will still be making IOLs 60 years from now. I don’t think many of our competitors will be,” says Donnie Munro, Rayner’s chairman and managing director. Unlike some IOL makers that have been swallowed up by multinational conglomerates, Rayner remains an independent firm. It is owned by the families of its founders and managers, and focuses on IOLs and related implant technologies, such as instruments and viscoelastics, Mr Munro notes. This gives Rayner the ability to create lenses customised to individual patient – and surgeon – needs rather than pressuring customers to commit to a one-size-fits-all lens solution as part of a cataract surgery package that includes purchase obligations for major equipment and procedure consumables. Mr Munro says that Rayner’s commitment to IOL development mirrors that of Ridley and other IOL pioneers. Their perseverance in the face of widespread condemnation by the ophthalmologic establishment is legend. Rayner was an active partner. Early collaborators include luminaries such as Edward Epstein in South Africa, Peter Choyce in the UK, Cornelius Binkhorst in the Netherlands, Benedetto Strampelli in Italy, Joachin Barraquer in Spain and Svyatoslav Fyodorov in Russia. The lenses made for these surgeons were truly custom, based on individual patient measurements and design preferences. “For years it was a money-losing division. It amounted to one person sitting at the end of a laboratory bench making the lenses,” says Mr Munro, who has extensively studied the firm’s archives since joining Rayner in 1989. By 1960 Rayner had produced 42 different designs that were implanted in human eyes, including some of the earliest toric lenses. Out of this, two anterior chamber designs emerged that proved pivotal in widespread IOL acceptance – the Choyce MkVIII in 1963; and the four-loop Binkhorst, first manufactured in Germany by Morcher in 1957, revised and introduced by Rayner in 1962 and modified by Fyodorov in 1968. Even so, IOL implants remained rare through the late 1960s, and Rayner produced just a few hundred lenses annually. By 1975, the tide turned. Following the International Congress of Ophthalmology in Paris in 1974, and Rayner’s develop- ment of the first modern posterior chamber lens with John Pearce MD in 1975, IOL demand skyrocketed. In 1979, 100,000 lenses were implanted in the US alone, of which one- quarter were Rayner. In 1981, two Rayner anterior chamber IOLs were the first approved as safe and effective by the US Food and Drug Administration. The era of mass produced IOLs had arrived. Procedures worldwide will exceed 15 million this year, with nothing but growth on the horizon. Rayner offers a wide range of lenses in the global mass market. Their worldwide success – including the 2007 US FDA approval of the C-flex – helped Rayner win the Queen’s Award for Enterprise in 2009, recognising the firm as among the most successful in the UK. Rayner currently supplies lenses in 67 countries, and regularly donates IOLs to charities serving developing countries. Rayner’s offerings include the C-flex standard and aspheric, Superflex standard and aspheric for larger eyes, T-flex toric, and M-flex multifocal and M-flex T toric multifocal are available in sphere and cylinder in 0.5 dioptre steps, with toric lenses available in 0.25 dioptre cylinder steps by custom order. All are available in a wider range of sphere and cylinder powers than many competitors. They feature anti-vaulting haptic technology, which allows the lenses to take up considerable compression due to postoperative capsular contraction without rotating, tilting or dislocating the lens in the z axis. Such stability is essential for the long- term success of both multifocal and toric lenses, Mr Munro notes. Rayner also has taken steps to reduce complications associated with the use of hydrophilic acrylic lens media, Mr Munro says. All lenses incorporate a 360-degree square- edge barrier – initially developed by David Apple and Michael Amon – that lies between the haptic and optic, preventing lens epithelial cell growth and resulting posterior capsular opacification. This makes it possible to take advantage of the strong points of hydrophilic acrylics compared with hydrophobic acrylics. These include greater clarity due to the complete absence of vacuoles and the build-up over time of water bubbles leading to glistenings, as well as a relatively low refractive index, which reduces interior reflections and chromatic aberrations. Hydrophilic acrylic lenses also have less adhesion to silicone oil, making them good choices for cataract patients who have had or may require retinal surgery, Mr Munro says. He believes hydrophilic lenses also hold promise for delivering medicines to the eye, much like drug-eluting stents in other surgical specialties. Possibilities include non-steroidal anti-inflammatory agents to reduce cystoid macular oedema, antibiotics to combat endophthalmitis, antifibrotics to reduce capsular contraction, or even agents to combat PCO. Yet in the midst of the industrial-scale success of IOLs, the individual needs of patients remain – and Rayner remains committed to meeting them, Mr Munro says. In addition to its mass-produced lines, Rayner also offers customised IOLs. Surgeons in many countries can order specially sized lenses; high power, low power and negative lenses; high astigmatic-correcting toric lenses; and multifocal toric lenses online to the Raytrace online ordering system or through Rayner customer service representatives. “We will look at any request. We have even made lenses for race horses,” Mr Munro says. He likens this custom service to a tailor, and believes it is necessary to meet some patients’ needs. “If this were a shirt, the other tailors would be saying, ‘if the collar is too tight, leave it unbuttoned.’ Whereas we’d have cut the shirt to fit the customer in the first place and so it is with lenses; we manufacture the lens to fit the patient.” In the inevitable cases where implanted lenses do not achieve emmetropia, Rayner provides the sulcus-fixated Sulcoflex lens, available in a wide range of sphere and cylinder powers. Because it is not inserted into the capsular bag, this design reduces problems associated with contact between the two lenses that arise with some other piggy-back designs, Mr Munro says. The Sulcoflex also is gaining popularity for use in paediatric patients because it is easier to remove and replace as patients grow than in-the-bag lenses. Rayner is developing new computer aided design and manufacturing technology that will allow even greater customisation to patients’ precise requirements, Mr Munro says. With this technology it may be possible within a few years to correct for things like asymmetric astigmatism and unusual corneal asphericity. Mr Munro sees a rapidly growing market for such lenses as more patients who have had LASIK or other corneal procedures develop cataracts. In collaboration with Charles Claoue, Rayner is also developing an implant for treating macular degeneration. This Fresnel lens redirects incoming light away from the diseased macula to healthy areas of the retina. In its initial implant in two patients, the lens eliminated the central scotoma, which may make it easier for patients to recognise faces and regain other functional vision, Mr Munro says. But while Rayner pursues advanced lens concepts, the firm is guided by an abiding concern for patient welfare, Mr Munro says. This is one reason why the firm has not yet pursued accommodating or microincision lenses, he says. The concepts are not yet proven over the long term, he explains. “I don’t lose sleep about the competition,” Munro says. “I lose sleep about doing something wrong for the patient. I ultimately want Rayner lenses in my own eyes.” djm-rayner-iol@hetnet.nl 38 Outlook on Industry On the 60th anniversary of the first IOL, Rayner sees a future in custom lensesby Howard Larkin 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

Industry News Regulatory Update Bromfenac for Europe The Austrian company Croma has submitted bromfenac to the European Medicines Agency (EMEA) for centralised approval throughout the EU for the treatment of postoperative ocular inflammation and pain following cataract extraction. The company will collaborate with Bausch & Lomb to promote and sell the non-steroidal anti-inflammatory drug in Europe. Bromfenac 0.09 per cent (Xibrom, ISTA Pharmaceticals) is approved in the US. Croma will market bromfenac with Bausch & Lomb in Austria, France, Poland, Romania, and Spain. Bausch & Lomb will also have the right to sell the drug throughout the EU and in Belarus, Croatia, Montenegro, Norway, Russia, Serbia, Switzerland, Turkey and Ukraine. Bromfenac is already approved in the US for b.i.d administration. Citing new study results, the company is now asking the FDA to approve once-daily dosing. www.croma.at www.bausch.com Herpes treatment approved The US FDA approved ganciclovir ophthalmic gel 0.15 per cent (Zirgan, Sirion Therapeutics) for the treatment of acute herpetic keratitis. The approval followed clinical trials conducted by Laboratoires Théa in Europe, Asia, and Africa showing comparability to acyclovir. www.siriontherapeutics.com New drop for allergic conjunctivitis Ista Pharmaceuticals received US FDA approval to market Bepreve (bepotastine besilate ophthalmic solution) for ocular itching association with allergic conjunctivitis in patients two years of age and older. www.istavision.com Industry News Alcon acquires ESBA Tech Alcon announced it would acquire Swiss biotech firm ESBATech AG. ESBATech develops single-chain antibody fragment therapeutics for topical and local delivery. The company has several stable and soluble single-chain antibody fragments in development. Early clinical trials are under way of compounds for the treatment of inflammatory ocular diseases. The agreement to acquire ESBATech includes all rights to its technology for therapeutic application to the eye, including age-related macular degeneration, diabetic macular oedema, glaucoma, dry eye and uveitis. Alcon will pay ESBATech shareholders $150m in cash at closing, plus contingent payments of up to $439m based upon the achievement of future research and development milestones. www.alcon.com www.esbatech.com Anticalin collaboration German biotech company Pieris announced a new collaboration with Allergan to develop treatments for eye diseases. Pieris concentrates its research in the area of anticalins, a novel class of biologic drugs engineered to bind disease-relevant targets with high affinity and specificity. Pieris will work with Allergan to optimise existing compounds and to develop new compounds. Allergan will cover all costs discovery, development, and commercialisation, as well costs for clinical development and related activities and commercialisation. www.pieris-ag.com www.allergan.com Bausch concentrates CL sites Bausch & Lomb announced it would consolidate worldwide contact lens manufacturing. The company plans a phased withdrawal from its production facility in Livingston, Scotland, during 2010 and early 2011. It plans to move most of its global contact lens production to its existing sites in Waterford, Ireland and Rochester, New York. www.bausch.com Product Launches New prostaglandin analogue Merck Sharp & Dohme has launched SAFLUTAN™ (tafluprost) in the UK and Spain. Tafluprost, the first preservative- free ophthalmic prostaglandin, is licensed in the launch markets for the reduction of elevated intraocular pressure in patients with primary open-angle glaucoma and ocular hypertension. Merck reached a worldwide licensing agreement with Santen Pharmaceutical company earlier this year. Merck will have exclusive commercial rights to tafluprost in western Europe (excluding Germany), North America, South America and Africa. Santen will retain commercial rights to tafluprost in most countries in eastern Europe, northern Europe and in countries in the Asia Pacific area, including Japan. If tafluprost is approved in the US, Santen will have the option to co-promote it there. www.merck.com www.santen.com New tools for Crystalens Bausch & Lomb Storz Ophthalmic Instruments released two new instruments for use during Crystalens surgery: the Brown Crystalens Haptic Placement Forceps and the Lindstrom Lens Positioner. The Brown Crystalens Haptic Placement Forceps have a “trident”-shaped tip designed to securely grasp the lens at the incision and position it in the capsule. The Lindstrom Lens Positioner features a semi- sharp angled tip that allows the surgeon to position an IOL by engaging optic material and is specially designed for the Crystalens and Akreos lenses to effectively facilitate movement of the lens in the capsule without marking it. www.storzeye.com Clinical Trials Presbia microlens enters trials The Flexivue System, an innovative approach to presbyopia developed by Presbia Coöperatief U.A. that was introduced at the ESCRS congress in Barcelona will enter clinical trials in Europe this year. The system includes a hydrophilic polymer lens, 3.0mm in diameter and less than 20 µm in edge thickness, which is placed within the corneal stroma via surgery using standard lasers used in LASIK. Ioannis Pallikaris MD, PhD, rector and director of the Institute of Vision and Optics of the University of Crete, will oversee the trials. www.presbia.com 39 Recent developments in the vision care industryIndustry News New websites for busy professionals Vision care marketers continue to develop innovative online communication tools. Three news sites demonstrate the potential of internet interaction for ophthalmologists. The first, from Abbott Medical Optics (AMO), is called AMOeasy. It is an online ordering service that allows surgeons to order IOLs and other products as easily as they now order books or tunes. Buyers register online and can then access a personalised database of products. The database allows the surgeon to check inventory, past orders, and usage patterns. Ever wonder what your patients are thinking? A new site from Bausch & Lomb, the Centre for Patient Insights, attempts to provide some clues in that area. Targeted at eye care professionals, the site provides market research on patient attitudes, along with suggestions on how to incorporate this information in practice. The site also provides related information on market trends. Long-term data on outcomes and adverse events following LASIK and other refractive procedures has been scarce. The European Registry of Quality Outcomes for Cataract and Refractive Surgery (EUREQUO) wants to change that. European eye surgeons are encouraged to sign up and register their own information, which can then be compared with that from other centres. Meanwhile, on the retina front, Carl Zeiss Meditec unveiled ‘Eye on OCT’ an online resource detailing the science and clinical applications of optical coherence tomography. The image-rich site includes educational videos, physician interviews and journal updates. www.amoeasy.com www.eurequo.org www.oct.zeiss.com EuroTimes now has its own Blog! Check it out on http://myeurotimes.blogspot.com for a unique online view on the world of ophthalmology

Feature “Judgement comes from experience and great judgement comes from bad experience” – Bob Packwood I n my judgement, there are no good or bad patients, only learning points to be taken for one to become a better physician. However, certain experiences and patients linger on in the mind, subconsciously modifying one’s attitude and actions. Further time modifies the viewpoint. Some cases which give so much heartburn may become something to laugh over later and yet others become cases one remembers along with a tinge of regret or loss. Patients are generally thought of as cases, battles to be won, surgical vistas to be conquered. The trusting, frightened, vulnerable individual that they become when they go under the knife is all but forgotten. The best and worst scenarios which I remember are the tremendous psychological impacts the pathology and the attempted remedy had on the patient. What is special in my case is that my best and my worst patient are one and the same. In India, one of the biggest festivals is Deepavali - the Festival of Lights. The whole of India literally explodes with joy. There are continued festivities: eating, dancing, merrymaking, and then of course... the crackers. Fire-crackers are a non-green thing to do, but one that not only all children look forward to but also one that brings out the child or at least memories of childhood in all adults. But sometimes, these times of joy and festivities may turn into a deluge of tears and the Festival of Lights can become a tragedy of darkness. One such patient was Baby A, a six- year-old girl who got injured while she was standing next to her brother and watching him light crackers. Well, little did the brother know that one of his crackers would actually bring darkness to his baby sister’s sparkling eyes. The cracker misfired in the wrong direction and instead hit her eye. She was rushed to the hospital where I happened to be on the night shift. I saw this beautiful girl with a red eye and a traumatic cataractous lens dislocated into the vitreous cavity. She was very brave and was trying hard not to cry. My heart went out to her. She was posted the next day for a vitrectomy with nucleus removal and a sutured scleral fixated IOL. Life seemed to have returned to normal for this spunky six-year-old till she started complaining to her mother about a year later that she was constantly seeing objects double when moving her eyes and head. Having a girl child in India is considered a burden amongst the lower socio-economic classes because of the associated baggage of having to pay huge sums of dowry at the time of marriage. Having a handicapped girl child can make it a lost battle, almost impossible to get her married off, and if at all married, probably doomed for a life of torture and mockery by her in-laws. Taking her case to be a lost cause and assuming that she was destined to be with them forever by the Gods of fate, her parents really did not bother any more about her. All further education was also stopped for her as she had now become a dead investment, not worth spending more on. Things continued as such until about six months later when her eye started becoming intermittently red and painful, something that the parents could no longer ignore. When I finally saw her again about two years after I first saw her, she was a ghost of her old self, preferring to stand quietly and not talk at all. Examination showed a subluxated IOL with one of the sutures having given way. The IOL was bobbing into and out of the visual axis with movements and was also causing pigmentary dispersion and uveitis. Her IOP was high. She seemed quiet and subdued, a pale comparison of when I had seen her last. The head of our institution had been performing for some time now, the new technique of the glued IOL, wherein the haptics of the IOL were externalised under two partial thickness scleral flaps and then tucked intra-sclerally into a pocket. The flaps and the haptics were then sealed down using fibrin glue. This seemed like the ideal case due to the lack of sulcus support and a failed previous sutured IOL. Also taking into consideration, her growing eye, we did not want to put in another sutured IOL. So, the path was set for performing a glued IOL and her big day came. She looked pale and wan, and as for me, I had prayed to all my Gods and promised offerings in return for her becoming alright. All I wanted was for her to return to her bubbly self again. As she was carried into the theatre, I sent up a silent prayer that this little child may get back to leading a normal life. The surgery went smoothly as planned and the next postoperative day was as smooth as anyone could have hoped for. As glue was used to close the conjunctiva, she was very comfortable. The lens was well centred and the eye was quiet. As days passed, her parents became more hopeful and with better attention from her parents, she started blossoming like a flower. When I saw her last, I learnt that she started going to school again and had even come first in the 100-metre dash in the annual sports day competition at her village school. The horror I experienced watching her transform from a bubbly child to a silent, withdrawn spectre made her my worst patient and the joy in watching her transform from this to her original self also made her my best patient. It was all that I could have ever hoped for as a doctor. Kaladevi Ranganathan was this year’s recipient of the John Henahan Prize. She received her award at the XXVII Congress of the ESCRS in Barcelona. 40 John Henahan Prize My best patient, my worst patient by Kaladevi Ranganathan June 17-19 In conjunction with Società Italiana Cellulle Staminali e Superficie Oculare (S.I.C.S.S.O) and refr@ctive-on-lineVenice 2010 Congress www.eucornea.org eucornea@eucornea.org E uCorne a European Society of Cornea and Ocular Surface Disease Specialists E uCorne a RegIStRatIOn OpenS: 10 november 2009 Call fOR abStRaCtS: Opens: 1 november 2009 Closes: 15 December 2009

41 The elusive goal of accommodation A truly functional accommodative IOL is still a dream, but a dream that appears closer to becoming a reality than ever before. JCRS co-editor Emanuel Rosen discussed the current state of the search for this grail. He notes that some compromise solutions now available have reached a degree of clinical acceptance. These include innovative refractive and diffractive bifocal and multifocal IOLs, hinged-optic IOLs, twin-optic devices, fluid-shift IOLs, smart IOLs, and a proposed electronic accommodating IOL. Yet all of these come with trade-offs, and achieve inconsistent results in terms of uncorrected visual freedom. He cites an article in the issue by Brown and colleagues that takes a real world look at two lenses now on the market that shows reasonable outcomes, but also demonstrates the challenges of measuring those outcomes. He also points readers to a promising study of the accommodating NuLens, a soft gel IOL using a piston and aperture device that achieves a reasonable range of accommodation, although not without some concerns for endothelial cell loss and PCO. Nonetheless, that study illustrates a big step in the evolution towards the long sought accommodative ideal. E Rosen, JCRS, “Accommodation: The dynamic range of vision”, (October 2009).Volume 35, Issue 10, Page 1655. D Brown et al., JCRS, “Functional reading acuity and performance: Comparison of 2 accommodating intraocular lenses”, Volume 35, Issue 10, 1711-1714. NuLens promising at one year Alio and colleagues present the one-year results of a small study of the NuLens in 10 eyes of 10 patients with cataract and atrophic macular degeneration. In each patient, the accommodating IOL was implanted in the eye with the worse visual acuity. The mean number of lines patients could read increased from 1.0 preoperatively to 3.8 lines six months postoperatively, indicating improvement in uncorrected near visual acuity after IOL implantation. Near visual acuity improved without compromising distance visual acuity. One-year evaluations suggested the lens achieved the IOL accommodation of 10.00 D. However, endothelial cell loss was statistically significant up to three months postoperatively and 60 per cent of eyes developed PCO in the first year. They note that a new square-edge design should solve the PCO issue. J Alió et al., JCRS, “Visual and accommodative outcomes 1 year after implantation of an accommodating intraocular lens based on a new concept”, (October 2009) Volume 35, Issue 10, 1671-1678. Making unhappy patients happy Patients unhappy with their results after refractive lens surgery can present a management dilemma to the surgeon. A new study looks at how well such patients do intraocular lens exchange following less than optimal outcomes with multifocal or accommodative lenses. 12 eyes of 10 patients received monofocal IOL exchanges. With a median follow-up of 8.9 months eight of the 10 patients were satisfied with the results of the exchange. One patient had a complicated postoperative course that necessitated repeat IOL exchange with scleral fixation due to inadequate capsule support. Another patient had corneal decompensation after the IOL exchange surgery. The investigators note that these results suggest this approach is a feasible option, but note that larger studies with longer follow- up are still needed. A Galor et al., JCRS, “Intraocular lens exchange surgery in dissatisfied patients with refractive intraocular lenses”, (October 2009) Volume 35, Issue 10, 1706-1710. Less dry eye with femtosecond flaps? US researchers compared the incidence of laser in situ keratomileusis (LASIK)-associated dry eye and the need for postoperative cyclosporine A treatment after flap creation with a femtosecond laser (113 eyes) and a mechanical microkeratome (70 eyes). The difference in mean central flap thickness between the femtosecond group (111 µm ± 14 [SD]) and the microkeratome group (131 ± 25 µm) was statistically significant (P<.001). The incidence of LASIK-associated dry eye was statistically significantly higher in the microkeratome group (46 per cent) than in the femtosecond group (eight per cent) (P<.0001), as was the need for postoperative cyclosporine A treatment (24 per cent and seven per cent, respectively) (P<.01). In the microkeratome group, there was no correlation between thick flaps and a higher incidence of LASIK- induced dry eye. M Salomão et al., JCRS, “Dry eye associated with laser in situ keratomileusis: Mechanical microkeratome versus femtosecond laser”, (October 2009) Volume 35, Issue 10, 1756- 1760. JCRS Highlights by Thomas Kohnen Journal of Cataract and Refractive Surgery jointly published by the ESCRS and ASCRSJCRS Highlights

A VISION OFCOLLABORATION Joseph Colin Chairman Department Ophthalmology University Medical School, Bordeaux, France Harminder Dua Chair and Professor Ophthalmology, University of Nottingham, UK Daniel Elies Cornea, Cataract & Refractive Surgery Specialist, Institut Microcirurgia Ocular, Barcelona, Spain José L. Güell Director of Cornea and Refractive Surgery Unit, Institut Microcirurgia Ocular, Barcelona, UAB, Spain Sadeer B. Hannush Attending Surgeon, Cornea Service, Wills Eye Institute, Philadelphia, USA François Malecaze Professor of Ophthalmology, Purpan Hospital, Toulouse, France Rudy Nuijts Director Cornea Clinic, Dep. Ophthalmology, Maastricht University Medical Center, Netherlands Ioannis Pallikaris Professor in Ophthalmology, Rector University of Crete, Greece Emanuel Rosen Visiting Professor Department of Vision Sciences, University of Manchester, UK Filippo Simona Cataract & Refractive Surgery Specialist, Centro LaserVis, Locarno, Switzerland Cornea & Refractive Surgery January 18–23, 2010 Scientific Coordinator: José L. Güell Further Information and Applications www.esaso.ch EuropEan School for advancEd StudiES in ophthalmology Università della Svizzera italiana Lugano, Switzerland FACULTY FIRST MODULE 2010

Bioluminescence imaging Bioluminescence imaging could allow early detection of ocular tumours and could be used to guide treatment, report Chinese researchers. A team in Shanghai engineered human RB tumour cell lines to express a fusion reporter gene allowing for bioluminescence and fluorescence imaging. The researchers were able to monitor the growth and succession of the tumours using the NightOwl LB 981 bioluminescence imaging system. The system allowed sensitive and quantitative localisation and monitoring of intraocular and metastatic tumour growth in a mouse model, and could prove to be a useful tool to study cancer biology as well as anti-cancer therapies in humans, they note. Xunda Ji, et al., Investigative Ophthalmology and Visual Science, “Non-invasive visualisation of retinoblastoma growth and metastasis via bioluminescence imaging”, 2009 doi:10.1167/ iovs.08-3258. (www.iovs.org) Rheopheresis for Dry AMD? Rheopheresis, a method of therapeutic aphaeresis using the methodology of double filtration plasmapheresis to treat microcirculatory disorders, is a controversial approach to the treatment of refractory dry AMD. German researchers report a randomised clinical trial suggesting that rheopheresis is a safe and effective therapeutic option for high-risk patients with dry AMD and no therapeutic alternative. They report a statistically significant mean difference of 0.95 ETDRS lines (p=0.01) between the rheopheresis and control groups at the primary efficacy endpoint of 7.5 months post baseline. Nine per cent of eyes in the group treated with rheopheresis gained two or more ETDRS lines, as compared with zero per cent of eyes with no treatment. According to the authors, none of the treated patients lost visual acuity, compared with 24 per cent of patients without treatment who lost one or more ETDRS lines. The treatment was well tolerated. Koss MJ et al., Graefes Arch Clin Exp Ophthalmol, “Prospective, randomized, controlled clinical study evaluating the efficacy of Rheopheresis for dry age-related macular degeneration”, 2009;247(10):1297-1306. Loss of vision, loss of life Non correctable vision problems appear to be associated with shorter lifespan in older adults. Australian investigators used data from the Blue Mountains Eye Study, which examined visual impairment in 3,654 participants age 49 and older between 1992 and 1994 and after five and 10 years, to evaluate the relationship between visual impairment and death risk among older individuals. At baseline, participants with non correctable visual impairment were more likely to be female, age 75 and older and underweight. Those with correctable visual impairment were more likely to be age 75 and older, but had no difference in proportions of women or BMI. Some 13 years later, 1,273 participants had died. A higher risk of dying was associated with non correctable visual impairment, with a stronger association for participants younger than age 75. Of mortality risk markers examined, only disability in walking demonstrated a significant indirect pathway for the link between visual impairment and mortality. MJ Karpa et al., Arch Ophthalmol., “Direct and Indirect Effects of Visual Impairment on Mortality Risk in Older Persons: The Blue Mountains Eye Study”, 2009;127[10]:1347-1353. (archopht. ama-assn.org) Computer mouse vector Although hospital computer equipment can act as a reservoir for pathogenic organisms, including MRSA, Chinese researchers found that bacterial contamination rates from computer equipment were relatively low. The researchers who studied IT equipment in a 1600-bed medical centre in southern Taiwan with 47 wards and 282 computers. The results revealed a 17.4 per cent (49/282) contamination rate of S. aureus, Acinetobacter spp. or Pseudomonas spp. The contamination rates of MRSA and A. baumannii in the ward computers were 1.1 per cent and 4.3 per cent, respectively. No P. aeruginosa was found. Po-Liang Lu et al., BMC Infectious Diseases, “Methicillin-resistant Staphylococcus aureus and Acinetobacter baumannii on computer interface surfaces of hospital wards and association with clinical isolates”, October 2009, 9:164. (www. biomedcentral.com/bmcinfectdis) 43 by Sean Henahan Vision science highlights from the world’s leading journals of medicine and scienceJournal Watch Journal Watch

45 O phthalmology and other specialties may ultimately benefit from a new “Solomon-like” ruling from Europe’s highest court. In October, the Court of Justice ruled that the EU’s competition law generally prohibits a pharmaceutical manufacturer from charging a drug wholesaler more for the drug if it knew that the wholesaler was exporting the drug to another EU company at a price below the manufacturer’s price in that other country. At the same time, the court also ruled that a pharmaceutical company could, in principle, make a case for an exemption to the general prohibition and charge that wholesaler more for the drug if it could establish that the wholesaler’s practice – known as “parallel trading” – ultimately robbed the company of the money necessary to fund the development of new drugs. The practice of parallel trading of pharmaceuticals has been a bone of contention in the EU for more than two decades. The practice is based on the varied costs of drugs between EU states. In the practice, drug wholesalers that operate in an EU country where the manufacturer’s price is lower buy the drug from the manufacturer at that price and use that price advantage to export and sell the drug in another EU country where the manufacturer’s price of the drug is higher. The particular case before the Court of Justice arose over the higher price that the pharmaceutical manufacturer GlaxoSmithKline (GSK) wanted to charge drug wholesalers in Spain who engaged in parallel trading. Because of the buying power of Spain’s national health service, the cost of pharmaceuticals there is generally lower than in most other EU countries. That difference makes Spain a prime country from which drug wholesalers engage in parallel trading with countries where the same drugs cost significantly more. Against that background, GSK, in March of 1998, drafted a new contract for its Spanish wholesalers in which it specified different drug prices for wholesalers according to whether those wholesalers resold the drugs in question in Spain only or exported them to another EU country. In so doing, GSK aimed to restrict the parallel trade in its medicines by some wholesalers between Spain and other EU countries where the GSK price was higher. The contracts were signed by 75 wholesalers established in Spain, which represented more than 90 per cent of GSK’s total sales in Spain in 1998. In charging different prices to discourage parallel trading, GSK hoped to come within the then-existing EU competition laws. At about that time, EU competition law forbade manufacturers from introducing a blanket ban on parallel trading but had not yet addressed the issue of differential pricing to discourage parallel trading. In September of 2008, the Court of Justice, in a case involving the Greek subsidiary of GSK, ruled that the pharmaceutical company could restrict the amount of drugs that it supplied to Greek wholesalers if it believed that the wholesalers were ordering extraordinary amounts of the drug for parallel trading to other EU countries. Details of that case and its implications appeared in the EU Matters column in the November 2008 issue of EuroTimes. This Spanish case arose because the Court of Justice had never before made a specific decision about the effect of differential prices on EU competition law. The case began in March of 1998 when GSK notified its Spanish wholesaler contract to the European Commission in order to obtain a decision declaring that the differential pricing was not prohibited by EU competition law or, failing that, a decision granting GSK an exemption for the agreement because it contributed to promoting the “technical progress” of developing new drugs. On 8 May 2001, the commission decided that GSK’s wholesaler contract was prohibited by EU competition law because it constituted an agreement restricting competition and because GSK failed to prove that the price differential had any “appreciable objective advantage” in promoting technical progress. After receiving the commission finding, GSK appealed to the EU Court of First Instance. That court agreed with the commission that the contract infringed EU law. However, that court also found that the commission failed to investigate adequately the company’s request for an exemption from EU competition law on the grounds of innovation. Two appeals, based on differing grounds, were brought against that judgment by GSK and by the commission. In the first appeal, the Court of Justice agreed with the commission and ruled the price differentials were anti-competitive. In so doing, the court found that the price differentials infringed EU law that prohibits any business from entering an agreement with another business to restriction or distort competition. In the second appeal, the court agreed with GSK that despite the general ban on price differentials, GSK still had a right to make its case with the commission for an exemption from EU competition law for its wholesaler contract on the basis of promoting the development of new drugs. In coming to its finding in the second appeal, the Court of Justice relied heavily on the opinion of the Advocate General, who had reviewed the case in depth and advised the Court of Justice about existing EU competition law. In the view of the Advocate General, the commission’s finding that there was no appreciable objective advantage was not based on adequate reasoning. “The commission cannot therefore disregard the submissions of an undertaking which relies on an economic argument and cites economic and econometric data which are relevant to it solely because no direct link is thereby demonstrated,” the advocate general wrote. “It can certainly refute in general terms submissions by an undertaking which are couched in general terms. However, where an undertaking backs up its arguments in a detailed and relevant manner, the commission must also deal with those arguments in a detailed manner.” “A reference to the possibility that extra resources may also simply be added to the company’s profits, since it is a matter of discretion for undertakings to decide how much they will invest in research and development, is not sufficient in that case. Such a general reference fails to have regard to the fact that the market conduct of undertakings may be influenced to a considerable extent by competition with other undertakings and that an undertaking’s discretion may be restricted by that.” The advocate general also highlighted the European Commission’s own policy for the EU single market in pharmaceuticals, which, he said, “emphasised the importance of competition in terms of innovation in the medicines sector, the continuous flow of new products onto the market, the particular features of the financing of investment in research and development, and the relationship to the profitability of undertakings.” In light of its ruling, the Court of Justice ordered the European Commission to re-examine the application of GSK for an exemption from existing EU competition law and to assess whether, on the facts as submitted by GSK, that it could establish a case for the exemption on the basis of promoting innovation. A decision from the European Commission is expected in the new year. Feature EU Matters by Paul McGinn EU court offers dual-effect pathway to reduce costs and promote innovation for drugs

Available to view now at www.escrsondemand.org n Symposia n Free Papers n Other Key Sessions Missed the XXVII ESCRS Congress in Barcelona? n Video Competition Winners n ePosters n Medal Lectures

47 Topcon receives 510(k) clearance for imaging system Topcon Medical Systems, Inc has announced that it has received FDA 510(k) clearance for the new TRC-NW7SF Mark II Digital Fundus Camera. This combines mydriatic and non- mydriatic functions into a single device which can capture retinal images through a dilated as well as an undilated pupil with high-quality results. The camera can be used to perform various documentation procedures, including intravenous fluorescein angiography, and non- mydriatic full-colour retinal screening for diseases such as diabetic retinopathy and glaucoma. “Observing images obtained from the NW7SF Mark II are comparable to viewing the same images through an ophthalmoscope; either in full colour or monochromaticmodes, all with minimal delay in image capture,” said a company spokesman. Product Update Product Update BD launches BD Visitec single-use microsurgical instruments BD Medical – Ophthalmic Systems, a unit of BD (Becton, Dickinson and Company), announced the worldwide launch of its expanded line of the BD Visitec stainless steel single-use instruments at the XXVII Congress of the ESCRS in Barcelona, Spain. With the addition of 30 new instruments and customised trays, the company says healthcare facilities have the potential to increase efficiency by eliminating the need for costly and time-consuming re-sterilisation of each product. “BD is pleased to expand our offering of single-use microsurgical instruments to meet the challenges of infection transmission prevention and help facilities around the world comply with strict safety requirements,” said Doug Lawrence, vice-president and general manager, BD Medical – Ophthalmic Systems. “This launch reflects BD’s continued commitment to developing safety-engineered, single-use medical devices to protect patients and healthcare workers against the threat of cross contamination and bloodborne diseases,” he said. CALLFORSUBMISSIONSNOWOPEN! BOSTON MASSACHUSETTS April7-9,2010 BsotonConvention&ExhibitionCenter BOSTON,MA PlanningCouncil: Chairs: MichaelW.Belin,MD DavidB.Glasser,MD MarkJ.Mannis,MD Committee: EdwardJ.Holland,MD MarianS.Macsai,MD R.DoyleStulting,MD,PhD JayneWeiss,MD InternationalAdvisoryCommittee: DenisedeFreitas,MD JosephFrucht-Pery,MD JoseGuéll,MD,PhD CharlesMcGhee,PhD,FRCOphth TeruoNishida,MD DonaldT.H.Tan,FRCS GabrielVanRij,MD Getthelatestupdateson... •RefractiveSurgery •PenetratingKeratoplasty/Keratoprosthesis •SelectiveLamellarKeratoplasty •DALK •InfectionsandImmunology •MedicalandSurgicalManagement ofOcularSurfaceDisease (includingneoplasia) •Biochemistry/Physiology/WoundHealing •MolecularGenetics/Dystrophies/Degenerations •Keratoconus,OtherEctaticDisorders: DiagnosisandTreatment •WorldHealth/EyeBanking SponsoredbyTheCorneaSociety Immediatelyprecedingthe2010ASCRS•ASOA AnnualSymposium&Congress PreliminaryTimeline: WednesdayEvening,April7,2010 RegistrationOpens WelcometoBostonReception Thursday,April8and Friday,April9,2010 ExhibitHallOpen ScientificandPosterSessions ExhibitHallWelcomeReception ImportantDates August5–November2,2009 CallforSubmissions September9,2009 RegistrationandHousingOpens January2010 PreviewProgram REGISTERONLINETODAY! www.corneacongress.org Nov09_Eurotimescorenaadvertical:Layout111/4/200911:28AMPage1 ASICO introduces hydrodissection cannula ASICO has announced the introduction of the Miyoshi Ultimate Vertical Dual Flow Hydrodissection Cannula for micro-coaxial cataract surgery. ASICO say the revolutionary design features two ports at 120° to facilitate complete hydrodissection the very first time without rotating the nucleus when used with a 5cc syringe. In cases where rotating the nucleus is necessary, the sandblasted tip enables the surgeon to work efficiently in the presence of visco. The Miyoshi Ultimate Vertical Dual Flow Hydrodissection Cannula is available in 23 and 25 gauge. ASICO Miyoshi Ultimate Vertical Dual Flow Hydrodissection Cannula TRC-NW7SF Mark II Digital Fundus Camera

November 2009 12-14 MOSCOw, RuSSIA S. Fyodorov Eye Microsurgery State Institution Xth Annual Meeting Tel/Fax: +7 499 9058051 Email: Boris.Malyugin@gmail.com 21-23 NEw DElhI, INDIA world ROP Congress 2009 Tel: +91 11 26593187 Fax: +91 11 26852919 Email: worldrop@gmail.com web: http://worldrop2009.org/ December 2009 3-6 ROME, ITAly 8th International Symposium on Ocular Pharmacology and Therapeutics Tel: +41 (0)22 5330 948 / Fax: +41 (0)22 5802 953 Email: oisha@isopt2009.com (Javascript must be enabled) web: www.isopt2009.com 4-5 lEIPZIG, GERMANy 5th International Congress of Corneal Cross linking web: http://www.cxl-congress.org January 2010 14-15 CAIRO, EGyPT The 4th RIO International Meeting “Cairo Middle East Ant Segment and Refractive Surgery Symposium” cosponsored with ISRS/AAO (The International Society of Refractive Surgery Of The American Academy of Ophthalmology) web: www.rioisrs.com 15 PARIS, FRANCE Macula of Paris Email: contact@maculaofparis.org web: www.maculaofparis.org 21-24 KOlKATA, INDIA The Joint Meeting of the 68th Annual Conference of All India Ophthalmological Society & 15th Afro Asian Congress of Ophthalmology Email: aiossecreteriate@yahoo.co.in lalitverma@yahoo.com web: www.aios.in www.aioc2010.com 29-30 MADRID, SPAIN 1st Foundational Congress of ASETCIRC (Spanish Association of Technology for Implantation of refractive and Corneal Surgery) web: www.asetcirc.org/congreso2010/ February 2010 12-14 BuDAPEST, huNGARy 14th ESCRS winter Meeting Tel: +353 1 209 1100 Fax: +353 1 209 1112 Email: escrs@escrs.org web: www.escrs.org 27-28 FRANKFuRT, GERMANy Frankfurt Retina Meeting 2010 Tel: +49 (0)69 3106 2972 / Fax: +49 (0)69 3106 3695 Email: c.eckardt@em.uni-frankfurt.de web: www.eckardt-frankfurt.de March 2010 4-7 PRAGuE, CZECh REPuBlIC 1st world Congress on Controversies in Ophthalmology (COPhy) Email: cophy@comtecmed.com web: www.comtecmed.com/cophy/2010 5-6 lJuBlIANA, SlOVENIA 4th ljubliana Refractive Surgery Meeting Tel: +386 1 510 2340 Fax: +386 1 5102342 Email: kmikek@morelaokulisti.si web: www.lj-refractive.com 8-9 COMO, ITAly International Congress on Imaging and New Treatments in Retinal Diseases web: www.mcaevents.org April 2010 10-14 BOSTON, MA, uSA ASCRS/ASOA Symposium and Congress Contact: ASCRS Tel: +1 703 591 2220 / Fax: +1 703 591 0614 web: www.ascrs.org May 2010 19-22 NATAl, BRAZIl XI International Congress of Cataract and Refractive Surgery web: www.catarata-refrativa.com.br/2010 June 2010 5-9 BERlIN, GERMANy world Ophthalmology Congress web: www.woc2010.de Email: pco@woc2010.org / pco@woc2010.de 17-19 VENICE, ITAly 1st EuCornea Congress Tel: + 353 1 288 3674 Fax: + 353 1 209 1112 Email: eucornea@eucornea.org web: www.eucornea.org July 2010 9-11 CRETE, GREECE Aegean Cornea X web: www.aegeancornea.gr 18-23 MONTREAl, CANADA ISER 2010 XIX Biennial Meeting of the International Society for Eye Research web: www.kenes.com/iser September 2010 PARIS, FRANCE 2-5 10th EuRETINA Congress Tel: +353 1 210 0092 / Fax: +353 1 209 1112 Email: euretina@euretina.org web: www.euretina.org 4-8 XXVIII Congress of the ESCRS Tel: +353 1 209 1100 / Fax: +353 1 209 1112 Email: escrs@escrs.org web: www.escrs.org 16-20 BEIJING, ChINA 25th Congress of the Asia-Pacific Academy of Ophthalmology (APAO) in combination with the 15th National Congress of the Chinese Ophthalmological Society (COS) Tel: (852) 2762 3125 / Fax: (852) 2715 9490 Email: secretariat@apaophth.org website: www.apao2010beijing.org October 2010 6-9 CRETE, GREECE European Assocation for Vision and Eye Research 2010 web: www.ever.be Email: ever@ever.be 16-19 ChICAGO, Il, uSA American Academy of Ophthalmology Tel: +1 415 447 0320 / Fax: +1 415 561 8576 Email: meetings@aao.org web: www.aao.org/annual_meeting 21-24 hAMBuRG, GERMANy 23rd International Congress of German Ophthalmic Surgeons Tel: +49 9113931625 / Fax: +49 9113931620 Email: doc@mcnag.info web: www.doc-nuernberg.de April 2011 26-30 SAN DIEGO, CA, uSA ASCRS/ASOA Symposium and Congress Contact: ASCRS Tel: +1 703 591 2220 / Fax: +1 703 591 0614 web: www.ascrs.org Abbott Medical Optics Tel: +49 7243 501 610 Fax: +49 7243 501 100 www.abbottmedicaloptics.com Pages: IFC, 16-17 Alcon Tel: +1 817 293 0450 Fax: +1 817 551 8968 www.alconlabs.com Pages: OBC, 3, 11, 41 Angiotech Tel: +1 604 221 7676 Fax: + 1 604 221 2330 www.angiotech.com Page: 35 ARC Laser Ag Tel: +49 911 217 790 Fax: +49 911 217 799 www.arclaser.de Page: 29 ASCRS / Eyeworld Tel: + 1 703 591 2220 Fax: + 1 703 591 0614 www.ascrs.org Pages: 34, 44, 47 Canon Europa N.V. www.canon-europe.com/medical medical.ophthalmic@canon-europe.com Page: 5 D.O.R.C International BV Tel: +31 181 45 80 80 Fax: +31 181 45 80 90 www.dorc.nl Page: 15 ESASO Laguno www.esaso.ch Page: 42 Excel Vision Tel : +49 (0) 7581 / 480647 Tel : +33 (0) 3 88 39 48 43 info@excel-vision.net Page: 21 Haag Streit International www.haag-streit.com Pages: 24 Hellenic Society of Intraocular Implant and Refractive Surgery www.hsioirs.org Page: 8 H.P. Braem Phone : +41 71 866 19 33 Fax : +41 71 866 19 80 Page: 18 Katena Tel + 1 9739891600 Fax + 1 9739898175 www.katena.com globe@katena.com Page: 10 Khairabad Eye Hospital www.mahendraeyeinstitute.com Page: 25 NIDEK Tel: +81 3 5844 2641 Fax: +81 3 5844 2642 www.nidek.com Page: 19 Oculus Tel + 49 64120050 Fax + 49 6412005295 www.oculus.de Page: 13 Oertli Instrumente AG Tel: + 41 71 7474 200 Fax: + 41 71 7474 290 www.oertli-instruments.com Pages: 43, 45 Rayner Intraocular Lenses Limited Tel: +44 1273 205401 Fax: +44 1273 324623 www.rayner.com Page: IBC WOC www.woc2010.org Page: 23 Calendar NovemberAdvertising Directory Ophthalmic Practice For Sale Ophthalmic Medical Practice for sale in South East Ireland. Solid patient base including excellent potential for surgical procedures. This well established second generation practice has an excellent reputation with over 50 years experience based in a prime central location of a major city. Special interests include Cataract, Glaucoma, Cornea, Refractive, Contact Lens and Orthokeratology. Further enquiries to: Kevin Hall, FCCA Hall Lifford Hall Registered Auditors & Chartered Certified Accountants Greyfriar Lodge 5 Greyfriars Waterford Ireland Tel: +353 51 879177 Fax: + 353 51 879186 E-mail: kevin@hlhwaterford.com