Monday, September 15, 2008

Controversy continues over intracameral antibiotic injection

To hear Ireland’s Peter Barry, MD, tell it, the evidence in favour of intracameral injections of cefuroxime to prevent endophthalmitis is incontrovertible. The 2006 ESCRS study showed a rate of 0.05 per cent in 8,000 patients receiving injections and antibiotic drops compared with a rate of 0.35 per cent in patients receiving placebo drops and no injection. Further, a 2007 study examining 225,000 patients from the Swedish registry, most of whom received cefuroxime injections, showed a similar endophthalmitis rate of 0.048 per cent, Dr Barry told a symposium on global practice choices at the XXVI Congress of the ESCRS. Similarly, those patient who were not treated with intracameral antibiotic injections showed infection rates very similar to the placebo group in the ESCRS study.

While these results have driven many European ophthalmologists to intracameral injections, they haven’t in many other parts of the world. For example, Dr Bissen-Miyajima reported that surgeons in Japan do not use intracameral antibiotic injections at all because there are no agents approved. Nonetheless, endophthalmitis rates in Japan also are in the 0.05 per cent range. Dr Bissen-Miyajima attributed much of it to the use of prophylactic antibiotic eyedrops. Her own research suggests that this cuts down on the bacterial load on the surface of the eye that is thought to be the root cause of most endophthalmitis infections. She also noted that most Japanese surgeons prefer a scleral incision because it has been shown in some studies to reduce endophthalmitis rates compared with clear corneal incisions.

Nick Mamalis, MD, of the US also emphasised the importance of both reducing infectious agents on the surface of the eye before surgery and carefully constructing incisions, particularly clear corneal incisions, to seal them against ingress of bacteria from the surface of the eye. A similar strategy was voiced by Jose Villar-Kuri, MD, who reported that many Mexican surgeons suture the incision to prevent infection. He reported a series of 12,000 cases without a single case of endophthalmitis by surgeons using this technique.

Dr Mamalis also pointed out that the fourth-generation flouroquinolones available in the US penetrate the surface of the eye, reducing the chances of infection. He also expressed concerns among US physicians about the lack of single-dose ophthalmic preparations of antibiotics leading to toxicity resulting from errors in dilution and preparation. However, he believes that should a single-use ophthalmic preparation become available, many US surgeons would use it.

Dr Barry commented that such preparations are being considered, but that maintaining stability of a solution in such minute quantities is difficult. He does believe the obstacle can be overcome. “The writing is on the wall. Let us read it and move on to the manufacture of cefuroxime in a single sterile FDA-approved unit dose for ophthalmic use.”

Dr Rosen pledges ESCRS support for surgeon education in developing countries

A new strategic plan being developed by the ESCRS Board will include new support for an ophthalmology training programme, said ESCRS President Paul Rosen, FRCOphth, at the opening session of the XXVI ESCRS Congress on Sunday evening. The commitment is the result of an ongoing strategic review process designed to identify and address future needs of European cataract and refractive surgeons, Dr Rosen said.

“Over the coming months the Board will formalise a strategic plan for the next three to five years,” Dr Rosen told the more than 5,000 delegates attending this year’s Congress. “This will include a significant investment to educate and support the training of new doctors, the future lifeblood of the society, especially from emerging European markets. It is my hope the process will enable the Society to continue to grow and meet the expectations of its members.”

The plan will be the product of an ongoing strategic review initiated by the Board under Dr Rosen’s leadership. “In recent years the Society has been tremendously successful,” Dr Rosen noted. “But the Board agreed there is a need to review structure and strategy to ensure we can continue to grow. We want to create a plan to ensure the Society addresses the requirements of a changing and expanding membership base, and establishes clear policies on issues such as education and engagement of the emerging and developing markets.”

The strategic review has been conducted in consultation with the Board, ESCRS Committee Members, industry, world opinion leaders and society members, Dr Rosen said. “If you haven’t yet had your say, please do so and contribute online.”

EU grant to support pan-European outcomes registry

Dr Rosen also outlined plans for a new European outcomes registry. “I am delighted to announce the ESCRS has received a substantial grant from the European Union. The purpose is to develop the European Registry of Quality Outcomes for Cataract and Refractive Surgery.” In addition to ESCRS, the project involves 12 European national societies. Funding is for three years and data collection begins in April 2009.

“ESCRS firmly believes that a continuing audit of surgical outcomes is needed to ensure the best care for our patients,” Dr Rosen said. He encouraged delegates to visit the project's booth on the ICC convention floor for more information.

Dr Rosen also highlighted the need for cataract and refractive surgeons to develop their business skills and highlighted ESCRS efforts to help out. “One of our new initiatives of the Congress has been the EuroTimes Practice Management Resource Centre, which offers a series of lectures on business topics such as marketing risk management and reimbursement. I think these topics are a vitally important adjunct to our meeting. It is important for ophthalmologists today to enable them to thrive and remain independent. It is our intention to build on this programme in future meetings. We will be working on this project with the London School of Business, the number one business school in Europe.”

Dr Rosen also acknowledged the ongoing contributions of German ophthalmologists to the ESCRS and invited delegates to enjoy the cultural and entertainment attractions of Berlin. “In 2003 the Congress was held in Munich. We are delighted to return to Germany five years later to the vibrant city of Berlin.”

Sunday, September 14, 2008

Toric IOL add-on offers new option for reducing pseudophakic astigmatism

Secondary implantation of a toric IOL is an effective method for correcting pseudophakic astigmatism, reported Haiying Jin MD at the XXVI Congress of the ESCRS.

Dr Jin spoke on behalf of his colleagues at the University of Heidelberg where a toric IOL has been used as an add-on implant in selected pseudophakic eyes with astigmatism related to either corneal toricity or rotation of a primarily implanted toric IOL. The implant used is a MicroSil toric IOL designed for piggyback implantation into the ciliary sulcus. Its spherical power, toric power, and alignment axis are determined based on calculation of the optical properties of the pseudophakic eye using a modification of the Holladay-Cravy-Koch vector analysis method.

Dr Jin demonstrated the utility of the piggyback toric IOL implantation in a case of a 72-year-old-man who received a toric IOL at cataract surgery and was found 20 months later to have more than 5 D of refractive astigmatism and almost 4 D of corneal astigmatism associated with a 60-degree off-axis rotation of the primary toric IOL.

“Repositioning of the primary implant would be challenging in this eye because it is 20 months post-surgery, and laser ablation is also not a good option considering the very high astigmatism and because the treatment axis and steep axis of corneal astigmatism are different,” noted Dr Jin.

“It is known that secondary IOL implantation is an effective approach for correcting refractive surprises after cataract surgery. To our knowledge, this is the first report of using a toric IOL as a piggyback implant to correct pseudophakic astigmatism.”

Near vision gains impressive after intrastromal femtosecond laser treatment for presbyopia

Preliminary results suggest intrastromal treatment using the Femtec femtosecond laser (20/10 Perfect Vision) is a promising new approach for presbyopic correction, said Sinan Goker, MD at the XXVI Congress of the ESCRS.

This flap-free, intracorneal procedure was developed by Luis Ruiz MD, Bogota, Colombia, in 2007. Dr Goker reported that he has been using the Femtec femtosecond laser since 2004 for flap creation and various other applications and has performed the intrastromal presbyopic treatment in 86 eyes of 51 patients since February 2008. All eyes were either emmetropic or slightly hyperopic, and each was treated with a customised photodisruption pattern based on keratometry, refraction, age and central corneal thickness. All patients were seen at one week and one month post-treatment, and two eyes had follow-up to six months.

Comparisons of baseline and postoperative data showed significant improvements were achieved in both mean UCNVA (from J13.3 to J2.3) and mean UCDVA (from 0.64 to 0.80). Whereas patients needed an average near add of +2.6 D to read J1 preoperatively, the same level of near vision was achieved at three months with a mean add of only +0.92 D.
BSCVA remained unchanged in 88 per cent of eyes, while one eye lost two lines and three eyes lost one line. Two of the latter cases resolved with treatment for dry eye. Mean BSCVA was slightly but significantly reduced from 0.99 to 0.95.

Corneal imaging using the Pentacam (Oculus) showed the intrastromal treatment caused no change in central corneal thickness while K1 as well as anterior and posterior surface asphericity were slightly increased.

“This is a very fast, non-invasive treatment for presbyopia with potential safety advantages relating to the absence of any flap or surface ablation, and unlike other presbyopia treatments, it does not disturb distance vision,” said Dr Goker, an ophthalmologist at Istanbul Surgery Hospital, Turkey.

“However, these are early results. Further follow-up in more eyes is needed to determine the long-term stability and predictability, and we are also developing nomograms for treating presbyopia in myopic and astigmatic eyes.”

Botulinum toxin injection plus refractive surgery play complementary roles


Botulinum toxin injection can be a useful adjunct to refractive surgery used either before surgery to treat existing oculomotor anomalies or postoperatively to address a secondary deficit of motor fusion, said Silvia Brogelli, MD at the XXVI Congress of the ESCRS.

Dr Brogelli presented findings from a retrospective review that identified 50 adult patients who had been treated between 1988 and 2008 with botulinum toxin injections into hyperactive extraocular muscles and also underwent refractive surgery.

The series represented two subgroups. Group 1 comprised 31 patients who had previously received one or more botulinum toxin injections for ocular misalignment or nystagmus and subsequently underwent refractive surgery. Group 2 included 19 patients with a history of refractive surgery who were subsequently treated with botulinum toxin to improve ocular motility. Cases with blind deviated eyes were excluded.

Considering that the benefit of botulinum toxin is time-limited and permanent stable binocular cooperation is reached in few cases, the time interval between repeated injections was used as a surrogate measure of comfortable binocular single vision and the criterion for measuring treatment efficacy.

There were no complications associated with the combination treatment. In patients who were receiving botulinum toxin as primary treatment for ocular misalignment, the mean interval between subsequent injections increased significantly after refractive surgery. Among the patients who received botulinum toxin to treat a secondary deficit of motor fusion after refractive surgery, all attained stable binocular cooperation either permanently (63 per cent) or with annual botulinum toxin injections (37 per cent).

“The sensorial changes caused by refractive surgery can affect oculomotor balance. Considering the well-recognised beneficial role of correcting hypermetropia in treating refractive accommodative esotropia, this change may be useful. On the other hand a potential for strabismic complications after refractive surgery exists,” said Dr Brogelli, Centro Oculistico, Firenze, Italy.

“Our experience shows that improving vision with refractive surgery in patients with intermittently deviated eyes being treated with botulinum toxin enhances fusion. In addition, botulinum toxin treatment provides patients the opportunity to be considered candidates for refractive surgery if they have been excluded because of poor binocular vision associated with hyperactive extraocular muscles.”

Gender factors into the equation for satisfaction after multifocal IOL implantation


Gender should be another factor to take into account when planning multifocal IOL implantation, according to the findings of a study presented by German ophthalmologist Magda Rau MD.

Dr Rau analysed possible gender-related differences in patient acceptance and satisfaction after multifocal IOL implantation using data from patients who underwent bilateral surgery with one of four different multifocal implants between 1999 and 2007. The IOLs were used during successive time periods and represented different optics designs. Between 1999 and 2001, 40 patients received the refractive Array multifocal IOL (AMO). From 2000-2001, 40 patients received the MF4 (Zeiss), a refractive multifocal lens with a near dominant zone. The diffractive Tecnis multifocal IOL (AMO) was implanted in 11 patients who underwent refractive lens exchange between 2004 and 2005, and the refractive ReZoom IOL (AMO) was implanted in 80 patients between 2005 and 2006.

Based on ratings of satisfaction, explantation rates, and complaints about near vision, far vision, and dysphotopsias, Dr Rau concluded implantation of a diffractive IOL in women is associated with higher satisfaction whereas men are more satisfied with their vision after implantation of a multifocal IOL with a refractive design.

“Men are hunters and women gatherers. Women attach more importance to reading print without glasses, but with their shorter arms, they also prefer a shorter reading distance. In contrast, men place more importance on clear distance vision and seem to be more troubled by problems with glare and haloes. In fact, the only patients who underwent explantation because of unsatisfactory distance vision, glare, and haloes were men,” said Dr Rau.

“Thorough counselling is important for all patients receiving a multifocal IOL, but this information suggests the patient education must be even more careful in men.”

Saturday, September 13, 2008

INTACS show excellent long-term results for keratoconus


Patients with keratoconus may derive long-term benefit from the implantation of intracorneal ring segments (INTACS, Addition Technology) in order to stabilise the progression of the disease and improve their visual outcomes, according to Joseph Colin MD.

Addressing delegates at the XXVI Congress of the ESCRS during a special clinical research symposium on keratoconus, Dr Colin said that the results of eight-year follow-up with INTACS suggests that they provide surgeons with a viable therapeutic alternative for ectatic diseases affecting the cornea.

“Our study demonstrated that INTACS segments are a safe and efficacious option for the treatment of patients with moderate to severe keratoconus who are contact lens intolerant. The improved functional vision associated with this treatment modality can defer or potentially eliminate the need for corneal transplantation,” he said.

Dr Colin, Hopital Pellegrin, Bordeaux, France, said that the broad goals of intracorneal rings in keratoconus are to stabilise the corneal topography, improve uncorrected- and best-corrected visual acuity, improve contact lens tolerance and spectacle use and delay the need for penetrating or deep lamellar keratoplasty.

Discussing the properties of the INTACS segments, Dr Colin noted that the clear micro-thin PMMA inserts are hexagonal in cross-section, with an arc length of 150°. The new model of the segments allows for an optical zone of 6.0mm compared to 7.0mm previously.

Reviewing the results of patients treated at CHU Bordeaux, Dr Colin said that the outcomes have been positive in 60 out of 65 eyes and have remained stable up to eight years after implantation. He also noted that penetrating keratoplasty could be carried out if necessary, as was the case for five patients in this study.

Dr Colin said that one of the clear advantages of INTACS implantation is that it is a fully reversible procedure.

“Removing INTACS is relatively straightforward once you follow the same steps as for the initial procedure. Using a diamond knife, you cut to two-thirds depth, reopen the incision and use Sinskey hooks to pull out the segments. You can then proceed with penetrating or lamellar keratoplasty in the same procedure,” he said.

Looking to the future, Dr Colin said that developments such as femtosecond-assisted creation of the channels for Intacs implantation, and synergistic approaches using ultraviolet collagen crosslinking to strengthen the cornea also hold considerable promise for the diagnosis and treatment of keratoconus.

Excellent long-term outcomes for ICL implant


Long-term clinical experience with the Visian Implantable Collamer Lens (ICL, Staar Surgical) demonstrates consistently high rates of refractive success, good safety and patient satisfaction, according to Carlo F Lovisolo MD.

“This lens has proved its viability and safety over the long-term with over 100,000 ICLs now implanted worldwide. From this experience and my own clinical experience of over 1,000 implantations, we can say that chronic IOP rise is not an issue with this lens nor are there any problems with chronic uveal inflammation. Once the proper sizing indications have been respected the ICL is safe for the corneal endothelium,” he said, speaking at the XXVI Congress of the ESCRS.

Dr Lovisolo, medical director, Quattroelle Eye Centre in Milan, Italy, said that three generations of the Staar ICL were implanted over the course of the 15-year study, the majority of which were the latest model, the V4, with improved vaulting to reduce the possibility of contact with the crystalline lens.

Dr Lovisolo noted that most late postoperative complications associated with ICL implantation, such as after-cataract and iridopathy, are size-related and can be thus avoided with proper anatomical measurements.

“We now know that sizing cannot be based on external anatomy as white-to-white measurements correlate poorly with internal dimensions. To correctly predict implant-to-tissue clearances, the ICL must be customised to the individual size and shape of the whole anterior segment as obtained with VHF echography,” he said.

Dedicated software to predict intraocular compression and vault height is also needed and implanted eyes should be monitored yearly after implantation, he concluded.

Corneal transplants safer and more efficient with femtosecond laser


IntraLase-enabled keratoplasty (IEK) represents the biggest advance in corneal transplantation in the last 30 years, said Yaron Rabinowitz MD, speaking at the XXVI Congress of the ESCRS.

“Using the femtosecond laser to perform corneal grafts leads to quicker visual rehabilitation, faster wound healing and safer surgery. It represents an excellent and safer new treatment option for keratoconus patients who are contact lens intolerant and is the only viable option when combined with LASIK or ICL implants for patients who want to become completely independent of contact lenses,” he said.

Dr Rabinowitz, director of ophthalmology research at Cedars-Sinai Medical Centre, Los Angeles, US, told delegates that the procedure results in high patient satisfaction and is easy to learn and to perform.

He noted that the femtosecond laser-assisted approach overcomes many of the inherent drawbacks of traditional corneal transplantation techniques such as long intraoperative duration, long visual recovery and the fact that many patients are left with residual postoperative astigmatism because the donor button has been sutured by hand.

IntraLase, which received FDA approval for full thickness penetrating cuts in July 2005, allows the user to perform three different cut segments, noted Dr Rabinowitz.

Discussing some of these cut profiles in more detail, Dr Rabinowitz cited the mushroom-shaped incision, which preserves more host endothelium than the traditional trephine approach. Another variation, he said, is the top-hat-shaped incision that allows for the transplantation of large endothelial surfaces, as well as a lamellar step for stronger healing and a reduced anterior surface area that is further from the limbus, possibly reducing rejection risk.

Yet another incision profile, popularised by Roger Steinert MD, is the zig zag–shaped incision providing a smooth transition between host and donor tissue and allowing for a hermetic wound seal. This type of incision provides oblique planes of contact and may potentially improve the strength of wound healing, said Dr Rabinowitz.

“This is my preferred cut. It can be performed on a larger surface area, promotes stronger and quicker wound healing and delivers an extremely smooth graft interface,” he said.

DLKP with bubble technique safe and effective to treat keratoconus


Deep lamellar keratoplasty (DLKP) using the injection of an air bubble appears to be a safe and effective procedure to correct keratoconus, Mohamed Alaa El-Danasoury MD told attendees at the XXVI Congress of the ESCRS.

“There is no endothelial rejection with DLKP, the procedure is safer in high-risk cases, it is reproducible and it enables a planned and controlled baring of Descemet’s membrane. Other benefits include the fact that there is no host-donor stromal interface, hence no endothelial rejection, it does not require excellent donor tissue and the refractive outcome can also be improved at a later date if required,” he said.

Disadvantages of the procedure include the learning curve needed to master the techniques involved and the fact that it cannot be performed when there are breaks in Descemet’s membrane, he added.

Dr El-Danasoury and colleagues at the Magrabi Eye Hospital, Jeddah, Saudi Arabia, reported on their results using the big bubble procedure to treat keratoconus in 87 patients.

He noted that the prevalence of the disease appears to be on the rise in his region.

“In the Middle East and Saudi Arabia, the prevalence of keratoconus is very high compared to countries in the west. We are seeing an average of four to five new cases every day and it is the foremost indication for corneal transplantation in our region,” he said.

In terms of patient selection for DLKP, Dr El-Danasoury stressed the importance of acting promptly to avoid the need for penetrating keratoplasty at a later stage.

“We do not let the patient wait until he is no longer a good candidate for lamellar keratoplasty. Our main concern is that we do not want the disease to progress to the point where the patient needs a full thickness graft. There is a very big difference between doing a lamellar graft versus a penetrating graft in these young patients with keratoconus because we are effectively nullifying the risk of having an endothelial graft rejection for the rest of their life,” he said.

The air-bubble technique was used in 113 eyes of 87 patients. All of them had moderate or advanced keratoconus and were dissatisfied with their corrected vision and/or hard contact lens wear, and all of them had intact Descemet’s membrane.

“We achieved Descemet’s separation using the big bubble technique in 91 per cent of the cases, with micro-perforations in seven per cent and we did not have to convert to a penetrating keratoplasty in any of the patients,” he said.

One year after the surgery, 84 per cent of patients recorded an uncorrected visual acuity of 20/40 or better, and 80 per cent were 20/40 or better three months after removing the sutures, concluded Dr El-Danasoury.

ESCRS welcomes delegates to Berlin

Delegates attending the Welcome Reception for the XXVI ESCRS Congress enjoyed an excellent selection of smooth sounds and international food and refreshments.

The reception, sponsored by AMO, was hosted at the Axel Springer Passage, close to the historic Berlin landmark Checkpoint Charlie. The Axel Springer Passage is home to the Axel Springer publishing company.

Axel Springer, established by the publisher of the same name in 1946, is Germany’s largest publisher with titles including Die Welt and Bild.

Friday, September 12, 2008

Dr Emanuel Rosen to announce winner of John Henahan prize in Berlin

The winner of the John Henahan Prize will be announced at the XXVI ESCRS Congress in Berlin on Saturday 13th September at 15.55 in Hall 15/2 as part of the Young Ophthalmologists programme.

Dr Emanuel Rosen, chairman of the Publications Committee of the ESCRS, will present a specially commissioned trophy to the winner.

Due to the high standard of a number of entries, two commendations will also be announced.

The winning entry will be published in the special Congress edition of EuroTimes on Sunday 14th September.

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