The sky is not falling - ophthalmology will survive

The Obama feel-good factor was not shared by all of those attending the joint meeting of the American Academy of Ophthalmology (AAO) and the European Society of Ophthalmology (SOE) in Atlanta, Georgia, US.

Big drops in the share price of the leading ophthalmic companies and reports from individual doctors of a reduction of more than 40 per cent in LASIK procedures in the last three months have put a dampener on the post-election celebrations for some doctors.

The global economic meltdown is showing up on the bottom line of finance companies specialising in LASIK and other discretionary medical procedures. Capital One and Care Credit both reported a slowdown in business in the past two months. Tightening credit standards mean it’s getting harder to qualify some patients for loans and default rates on outstanding commitments are climbing.

But every cloud has a silver lining and one of the biggest growth areas in the next 12 months will be the market for practice management consultants and practice management seminars.
Ophthalmologists in the desperate search for a bang for their buck can expect to be bombarded with literature inviting them to pay top dollar for seminars on topics including, "Good news in a depression" and "The sky is not falling".

But ophthalmology, like other medical disciplines, should not be just about money and while doctors should also listen to the advice of practice management experts and other economic consultants, they should also set themselves standards that they will strive to achieve in good times and bad times.

This point was emphasised at the Meet the Masters presentation, sponsored by AMO, where residents attending the AAO/SOE meeting were invited to hear pearls of wisdom from Dr Michael Colvard (pictured above), Dr Bobby Osher and Dr Ralph Chu.

We won't go into a speaker-by-speaker check list of the individual messages from the masters but below are some of the pearls of wisdom they offered to the young doctors attending the meeting.

* Never ridicule anyone's new idea.
* People will forget everything you tell them but they will never forget how you make them feel.
* It's a very small world. Be honest when you speak.
* Always ask yourself what do you like doing and be passionate about what you do.
* It's not always about economic gain.
* Don't allow yourself get stale.
* Treat your patients like you would treat your families.
* You can't always cure but you can always comfort.
* Nobody can train you how to develop emotionally as a doctor.
* Never get cocky about your surgical skills.

Ophthalmology in the new Europe

This month EuroTimes looks at ophthalmology in the new Europe. Among those featured is Levon Barseghyan, MD, professor and head of the Ophthalmology Department of the National Institute of Health in Armenia.

Dr Barseghyan (pictured above) says his country faced a lot of difficulties after the break-up of the Soviet Union, but ophthalmologists have continued contacts with the major centres in Moscow and Ukraine.

Dr Barseghyan, who studied at the Filatov Eye Institute in Odessa, Ukraine and in Moscow, says that while contacts among Russian-speaking ophthalmologists are not as frequent as before, they continue. And that is why the Fyodorov meeting is so important, he says.

Other major influences on Armenian ophthalmology come from outside the region. One such influence is Roger Ohanesian, MD, the founder of the Armenian EyeCare Project. Dr Barseghyan explains that Dr Ohanesian has brought doctors to Armenia from abroad, helped to train Armenian doctors in the US, and donated such equipment as phaco machines. “He has also brought a mobile hospital to Armenia, which is very well equipped,” Dr Barseghyan adds.

While older ophthalmologists continue to promote ophthalmology in their countries, the future of the specialty lies with a new generation of young Armenian ophthalmologists, Dr Barseghyan says.

“There are better opportunities for our young ophthalmologists than there was in my time,” he says. “They can travel to international conferences, they can gather information from the Internet. By getting more knowledge, they can become better doctors.”

Ophthalmologists are never at war

Political tensions may continue to cast a shadow over relations between Russia and some of the other countries that were once part of the Soviet Union. Despite such clouds, the clear message from the delegates attending the recent IXth International Congress of the Russian Society of Ophthalmologists is that the international brotherhood and sisterhood of ophthalmology is, if anything, growing stronger.

This point is strongly borne out by Merab Dvali, MD, professor and chief of the Eye Department at the Tbilisi State Medical University Ophthalmology Department in Georgia.

“Years ago we were one big country with a common education, the same teachers and the centre of ophthalmology in the Soviet Union was Moscow,” Dr Dvali remembers during a break in the congress at the Fyodorov Complex in Moscow.

“I worked in Moscow for 19 years, and it continues to be a very important centre. Unfortunately, over the last 12 months, we have had political differences with Russia but I think the doctors in both of our countries have stayed friends. We were, and will be, brothers and sisters. We have no borders. Ophthalmologists never war. I hope our governments will take the same approach."

Dr Dvali says for Georgian ophthalmologists it is very important to have close links both with Russia and other European countries.
“It is very difficult for our patients to go abroad and get treatment. We are a small country and we do not have enough eye surgeons, but we are doing our best and we try to use the latest technologies.”

While state-funded clinics in Georgia often struggle for funds, an increasing number of private clinics are being developed, says Dr Dvali. Young ophthalmologists in Georgia are also being encouraged to travel overseas for training. “We are supporting one young doctor who we have sent to India to get training in vitreo-retinal surgery. He knows the theory, but he needs practical experience and in India he will get that experience. Another doctor has gone to Spain to study keratoplasty surgery.”

So what should be the model for developing ophthalmology in Georgia? While Dr Dvali is full of admiration for the work done at the Fyodorov Complex, he does not think that a complex of that size should be replicated in his country.
“It is my opinion that eye clinics should not be as big as Fyodorov. Under the old socialist system it was possible to build a big clinic like Fyodorov, but I do not think it is necessary to have a complex of that size,” he says. “For example, my own clinic is a 200-square-metre outpatient clinic. We do laser, we do phaco, and we do all surgery in this clinic. The most important thing is good equipment and good doctors.”

In 1999, Prof Dvali bought the first excimer laser into his clinic. “It was very difficult to raise the money,” he recalls. “But I was able to raise the finance with the help of five friends who were not ophthalmologists. They believed in me and they supported me and that was very important.”

Because of the lack of resources in government clinics – like the one he runs – Dr Dvali is using his private clinic to train his residents.
He notes that in many western European countries, ophthalmologists are concerned about the growth of the private ophthalmology sector at the expense of the public sector. In Georgia, however, private clinics are essential for the development of ophthalmology, he says.

“Public and private patients get the same treatment,” he says. “We also have a mobile clinic that allows us to go to small villages and carry out surgery. If a patient does not have money, he does not get a poor service.”

* A full report on Ophthalmology in the new Europe will be published in December EuroTimes. You can also visit our website at www.eurotimes.org

ESCRS booth draws a crowd

The ESCRS Winter Meeting in Rome is attracting lots of interest from ophthalmologists attending the AAO/SOE meeting in Atlanta. Doctors from the US and elsewhere are flocking to the booth to sign up for the ESCRS Winter Meeting, the EURETINA meeting in Nice and the 2009 Congress in Barcelona.

The high quality of the scientific content of all three programmes are big draws for US ophthalmologists and the recent decline of the euro against the dollar and lower costs for airfare are making the trip more attractive for folks on this side of the pond.

Ophthalmologists check out new WaveLight laser

Though it won’t be available until the end of 2009, demonstrations of WaveLight’s just-revealed UltraFlap femtosecond laser concept platform drew a steady stream of interested ophthalmologists – as well as a few spies from the competition – throughout the day. The 200 kHz system will be capable of cutting a LASIK flap in under 15 seconds, matching or bettering the performance of the fastest lasers currently on the market, according to Mario Klafke, WaveLight’s director of product management for ophthalmology.

Designed to enhance quality, safety, comfort and efficiency, the laser’s high repetition rate, small focal area and low pulse energy produce exceptionally smooth flap surfaces with sharp edges that make flap lifting easy, Mr Klafke added. Tests on pig eyes show low standard deviation in flap thickness. The UltraFlap integrates seamlessly with the Allegretto excimer platform. The two can be placed side by side, allowing the patient to be rotated from one to the other during a procedure in an office space as small as nine square metres. They also share data, enabling safety features such as a warning if the surgeon chooses a flap size too small to accommodate the ablation zone. UltraFlap also supports other surgical applications, including sub-Bowman keratomileusis, intracorneal ring segments, lamellar keratoplasty, penetrating keratoplasty and self-sealing keratoplasty.

Faith affects treatment compliance in glaucoma

A broad awareness among ophthalmologists regarding the religious beliefs of the patient groups they treat will allow them to formulate management plans in keeping with these beliefs without compromising care, according to research presented at the joint meeting of the American Academy of Ophthalmology (AAO) and the European Society of Ophthalmology (SOE) in Atlanta, Georgia.

Increasingly, ophthalmologists care for patients of diverse backgrounds and this trend is accelerating the need for reliable information on the interaction of religious beliefs and compliance with prescribed treatments.

The effectiveness of glaucoma treatment, in particular, often depends on patients’ ability and willingness to self-administer eye drop medications on a regular schedule over months or years. Glaucoma patients often notice no symptoms in the early stages of the disease, which poses challenges for physicians in motivating patients to stick to treatment regimens. If patients neglect treatment until their vision noticeably declines, the damage is often irreversible.

Many of the world’s religions practise obligatory or voluntary fasting (abstaining from food and often also fluid) during periods that can last from a few days to more than a month, on an annual basis. Researchers led by Nishant Kumar, MBBS, of the University Hospital, Liverpool, UK, studied patient compliance in relation to fasting by analysing 350 surveys completed by members of the world's major faiths: Islam, Hinduism, Jainism, Christianity, Judaism, Bahai, and Buddhism (50 surveys per religion) — the first study of its kind, the researchers believe.

Population reports show that approximately 20 per cent of the world’s people are Muslim and about 15 per cent are Hindu; fasting is important to both religions. It is mandatory during the daylight hours of the month of Ramadan for Muslims; for Hindus fasting is generally voluntary.
Dr Kumar’s team previously surveyed Muslim patients on their use of prescribed eye drops during Ramadan and concluded that treatment compliance was significantly reduced in patients who kept the fast. If patients reduced or stopped their glaucoma treatment for an extended period, such as the month of Ramadan or other continuous fasting periods, their vision could be adversely affected.

In the new survey, the majority of patients self-identified as Hindus, Muslims and Jains stated that the use of eye drops during their fasting hours would break their fast, and therefore they would not use drops while fasting. However, these patient groups said they would be more likely to use drops while fasting for painful eye conditions or if vision was affected. The majority of Christian, Buddhist, Bahai and Jewish survey respondents did not believe that using drops would break their fasts, and stated that they would use eye drops during their fasting periods.
“A broad awareness among ophthalmologists regarding the religious beliefs of the patient groups they treat will allow them to formulate management plans in keeping with these beliefs without compromising care,” said Dr Kumar.

Unity brings progress in society and ophthalmology

Letter from Berlin

by Howard Larkin

In a 1991 afterward to his classic history The Germans, Stanford University scholar Gordon A Craig wrote, “there is every indication that the united Germany will be the strongest pillar” of a strengthened European community. One has only to walk the streets of Berlin – or listen in on a few ESCRS scientific symposia – to grasp the prescience of this assessment. Indeed, evidence of the benefits Germany has reaped from reunification, and its contributions to the world as a result, are evident throughout this city of 3.4 million people.

In Potsdamer Platz, €4bn worth of sleek buildings have sprung up where nothing existed but a barren strip of no-man’s land divided by the Berlin Wall during the Cold War. Recent developments include the Arkaden, one of Europe’s largest shopping centres, and the modern architectural landmark Sony Center, as well as the Daimler Benz complex and several luxury hotels. While the impact of Sony’s and Daimler’s recent sales of their Berlin properties remains to be seen, these developments have restored the area to its former position as one of Europe’s most vibrant commercial and entertainment zones.

Other commercial areas throughout the eastern part of the city also have been rejuvenated, including Hackescher Market, which has become a thriving artistic and cultural centre, and the area around the New Synagogue. In the west, all it takes is a look down the TauentzienStrasse, another of Berlin’s most prosperous commercial districts, toward the ruin of the Kaiser Wilhelm church’s bell tower, preserved as a war memorial, to see how far Berlin has come in a few short decades. Major construction continues across the city, a testament to the power of what an open society can accomplish.

In his opening speech to the XXVI Congress of the European Society of Cataract and Refractive Surgeons at the International Congress Centrum here, ESCRS President Paul Rosen, FRCOphth, acknowledged the ongoing contributions of German ophthalmologists to the ESCRS. “In 2003 the Congress was held in Munich. We are delighted to return to Germany five years later to the vibrant city of Berlin.”

As befitting its location as the traditional crossroads of east and west, the Berlin Congress produced plenty of the healthy debate that has strengthened the field of ophthalmic surgery so much over the past few decades. As at past ESCRS meetings, ophthalmologists aired differing views on a number of issues – like increasing the use of topical anaesthetics and using toric lenses to control more-severe astigmatism. That debate also touched more raging controversies, such as the impact of blue-blocking IOLs on patients and the use of intracameral antibiotics in cataract surgery.

In the true spirit of respectful listening and learning that is the hallmark of open societies, some progress was evident. For example, surgeons on both sides of the intracameral antibiotic injection controversy agreed that introduction of a single-use, unit dose of cefuroxime would go a long way toward overcoming objections to the procedure, particularly in the US. The role of keeping the eye surface clean and treating prophylactically with antibiotic eye drops, and even going back to suturing cataract incisions to prevent the influx of infectious agents after surgery were also put forward by presenters from Japan and Mexico.

Also on display were several examples of the technical and business innovations produced by the open business environment, technical traditions, and entrepreneurial spirit of Germany. Among the innovators is Carl Zeiss Meditec. Based in Jena in the former East Germany, the firm recently sold its 10,000th optical coherence tomography diagnostic system. This same company that invented the IOLMaster and recently released a surgical microscope that offers higher contrast and better depth perception for better visualisation of delicate ocular tissues during surgery. The firm also recently acquired Acri.Tec, manufacturer of advanced intraocular lenses in a suburb of Berlin. “In every product we offer we want to fulfil our brand promise,” said Michael Kaschke, Zeiss’ new CEO. “We want to be known for superior technology and optics precision.”

Not to be outdone, WaveLight, the German manufacturer of excimer lasers and other ophthalmic devices acquired last year by Alcon, released a new biometry device known as the Allegro Biograph. It uses optical low coherence reflectometry to precisely measure axial length and anterior chamber measurements in a few seconds without touching the eye. WaveLight lasers continued to expand their market share in Europe while expanding in a US market still overwhelmingly dominated by AMO’s VISX.

On another business front, Schwind eye-tech-solutions of Kleinostheim, Germany, and Ziemer Ophthalmic Systems of Port, Switzerland, announced an alliance to market Schwind’s advanced Amaris excimer laser and Ziemer’s Femto LDV systems as an integrated package to refractive surgeons looking for an all-laser LASIK solution. “With the combination of these two state-of-the-art lasers, a new level of quality of LASIK surgery has been achieved,” said Rolf Schwind, Schwind’s CEO. Both companies will continue to offer their products separately as well. The alliance is a response in part to the integrated all-laser approach now heavily marketed by AMO.

Intriguing as these technical debates, innovations, market manoeuvres and geopolitics may be, perhaps the real value of it all was best expressed by Nigel Morlet, MD, of Royal Perth Hospital in Western Australia. He presented a retrospective of cataract surgery outcomes from 1980 to 2001 in Western Australia that showed a 67 per cent decrease in major complications including endophthalmitis, lens displacements, pseudophakic bullous keratopathy, and retinal detachments that required a second operation.

Dr Morlet chalked up the progress to technical innovations, most especially the introduction of phacoemulsification. “We all should be proud of this because attending meetings like this is where we learn how to do things better and then go home and try to do the best for our patients, and this is reflected in these numbers. The surgery we do today is not just our own capabilities, but the capabilities of our colleagues who teach us new approaches and techniques.”

Such are the multiple benefits of opening the doors between east and west.

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.”

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

BERLIN
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

Berlin

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

Berlin

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.”

INTACS show excellent long-term results for keratoconus

BERLIN-

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

BERLIN-

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

BERLIN-

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

BERLIN-

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.

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.

For further information also go to our website at www.escrs.org

Judging for Henahan Prize begins

The judges have started work on deciding who will be the inaugural winner of the John Henahan prize for young ophthalmologists.

A distinguished panel of ophthalmologists and medical writers including Emanuel Rosen,FRCS, Jose Guell, MD, Sean Henahan, editor, EuroTimes and Paul McGinn,editor, EuroTimes will judge the entries from members of the ESCRS who are under 40 years of age.

Entrants were invited to write a 1,000-word article on “Why I became an ophthalmologist”.

The winning entrant will receive a prize of €1000 that will be awarded at the XXVI ESCRS Congress in Berlin,2008 in September. We will publish the winning entry in the October edition of EuroTimes.

Thanks to everyone who entered the competition. No correspondence will be considered once the judges have announced their decision.

Two weeks left to enter the John Henahan Prize

There are only two weeks to go before the closing date for the John Henahan prize.

A distinguished panel of ophthalmologists and medical writers including Emanuel Rosen,FRCS, Jose Guell, MD, Sean Henahan, editor, EuroTimes and Paul McGinn,editor, EuroTimes will judge the entries.

John Henahan was the visionary editor and guiding light of EuroTimes from 1996 to 2001 and his work has inspired a generation of young doctors and journalists, many of whom continue to work for EuroTimes.

Ophthalmologists who are members of the ESCRS and who are under 40 years of age are eligible to apply for the prize.

Entrants are invited to write a 1,000-word article on “Why I became an ophthalmologist”.

The article should give a brief introduction into why the individual ophthalmologist decided on his or her career path and should include reference to his early education,including mentors and role models. The article should also look at issues and controversies in ophthalmology, including changing demographics and evidence based medicine. The closing date for entries is Friday,August 1,2008.

The winning entrant will receive a prize of €1000 that will be awarded at the XXVI ESCRS Congress in Berlin,2008 in September. We will publish the winning entry in the October edition of EuroTimes.

To apply, please e-mail your article, to Colin Kerr, executive editor, EuroTimes at colin.kerr@escrs.org. Your e-mail should include your full name,home address and phone number,your date of birth and ESCRS membership number.

•Entries received after August 1 will not be considered. The decision of the judges is final and no correspondence will be considered once they have announced their decision.

Four’s a crowd - femtosecond lasers compared

Femtosecond laser refractive surgery first entered the clinic in 2001 with the FDA approval of the IntraLase system. That system is now in its fifth iteration, and has since been joined by three other femtosecond laser platforms. EuroTimes got an update on the features, performance, and applications of the individual lasers at a refractive surgery session at the WOC.

Comparing and contrasting

Holger Lubatschowski PhD, Germany, began the session by providing an overview of basic principles of femtosecond laser performance and a side-by-side comparison of the technical features of each of the four commercial platforms. All of the femtosecond lasers use photodisruption to cut through corneal tissue, and they all operate at a wavelength of about 1040 nm, but they differ in a number of technical respects.

The Femtec (20/10 Perfect Vision) and IntraLase have a high pulse energy, the LDV (Ziemer) has a very low pulse energy, and the VisuMax (Zeiss) lies somewhere in between. With the IntraLase, Femtec, and VisuMax, the cutting process is directly visible to the operator, whereas it is seen only on the monitor using the LDV. The Femtec and VisuMax have a spherical contact interface to the cornea, while the VisuMax has a contact glass for corneal fixation.

The LDV delivers its laser beam through a mirror arm that fits under all excimer lasers and consists of just an oscillator without an amplifier. Therefore, the LDV can be used without moving patients during the surgical process, and it is also the smallest of the devices.

The four femtosecond lasers also differ in pulse width, which ranges from 250 femtoseconds for the LDV to 500 femtoseconds for the IntraLase and Femtec. The repetition rate is in the MHz range for the Femtec and in the kHz range for the other platforms, while pulse energy is in the nanoJ range for the LDV and in the milliJ range for the others.

IntraLase

Perry Binder, MD, US, presented worldwide clinical experience with the IntraLase femtosecond laser. Since the introduction of the first generation system, the IntraLase platform has been used to perform more than two million procedures, including over 500 IntraLase-enabled keratoplasties. Other uses have included astigmatic keratotomy, wedge resection, lamellar keratoplasty, penetrating keratoplasty, creation of INTACS channels, and corneal biopsy.

The recently introduced 5th generation device provides a number of important features and benefits. This 150 KHz femtosecond laser allows reductions in time for flap creation and total energy delivery. It also permits unique methods of flap customisation, including a bevel-in sidecut angle, which has been shown in various studies to result in stronger flap healing.

The newest IntraLase laser also offers a high-resolution video microscope for increased depth of focus during surgery, a touchscreen user interface, and digital video output.

“We think the fifth-generation IntraLase laser enables most of the idealised goals of LASIK surgery better than any currently existing femtosecond laser while placing all the tools necessary for customising the flap within the hands of the surgeon,” Dr Binder said.

Femtec

The Femtec is a highly capable workstation that is also able to perform roles beyond LASIK flap creation, said Julian Stevens, MD, UK.

A key feature of this platform is that it has a curved patient interface that is important because it translates into less distortion of the cornea and less compression of the eye. Therefore, IOP is minimally increased.

The Femtec also features excellent diagnostic graphics on the video screen that are particularly useful for monitoring shape when cutting corneal grafts, a torque feature that detects patient head movement, and a direct diagnostic link with customised treatments.

In addition to having proven itself as a capable flapmaker, the Femtec laser has been used for astigmatic keratotomy, intrastromal astigmatic keratotomy, and cutting corneal grafts.

However, the capability that most distinguishes it from other existing platforms is its potential to be used to perform intrastromal refractive surgery with no flap.

“The Femtec laser is a very capable workstation with excellent software. It is one of the most sophisticated and advanced systems available today and may bring us to the Holy Grail of femtosecond lasers, which is to use this technology to put energy into the cornea in order to achieve a shape change without cutting a flap,” Dr Stevens said.

LDV

Theo Seiler MD, PhD, Switzerland, discussed the Ziemer LDV based on his experience over the last two years. His presentation delivered three messages relating to precision, safety, and platform dependability.

After proposing that a femtosecond laser has a role in refractive surgery for procedures where flap dimension precision truly matters, Dr Seiler reported that in a series of 92 eyes undergoing creation of flaps with an attempted thickness of 110 microns, the mean ± SD thickness was 109 ± 3.7 microns with a range from 101 to 116 microns. Flap diameter outcomes also showed sufficient precision and reproducibility, although Dr Seiler noted that the desired flap diameter is obtained only if the suction is complete.

Safety has been excellent. Complications encountered in the last 200 patients consisted of strong adhesion necessitating manual cut in two eyes, failure of the scan in one eye, too small flap diameter in one eye, and inability to perform two treatments because of a small eye and deep orbit. There were no air bubbles in the anterior chamber or eyes with transient light sensitivity, and eyes with Sands of Sahara have been very infrequent.

The LDV has also proven itself to be an easy-to-use and dependable workhorse, he noted.

“We have had to cancel only one surgery session over the last two years and consider this platform a Volkswagen, not a Ferrari. There is no need for a technician, no calibration, and no extra temperature and humidity controls. We know that with the LDV, we can just turn it on, and it goes,” Dr Seiler said.

VisuMax

As described by Marcus Blum MD, the VisuMax platform (Zeiss) is an integrated solution combining a femtosecond laser and excimer laser. It uses a spherical contact interface system to the cornea with low suction pressure so there is no vision loss during suction, and treatment positioning is precise as the patient fixates on a blinking light within the system.

A study using high-frequency digital ultrasound to measure flap thickness showed it performs reliably and precisely for flap creation. In a series of eyes with an attempted thickness of 110 microns, the mean achieved was 112 microns, 25 per cent of eyes were within two microns of intended, and 88 per cent were within 10 microns.

However, ongoing research using the VisuMax femtosecond laser for femtosecond lenticule extraction (FLEx) as a new method of refractive surgery is what is distinguishing this platform, said Dr Blum.

He presented data from six months of follow-up of more than 100 eyes showing good safety, refractive stability, and reasonable accuracy but with slight overcorrections in lower myopes.

“We have been very grateful to use this system because it works perfectly for LASIK flap creation. However, we have tried to take the VisuMax beyond the point where it is only a flap maker. Obviously there is a learning curve, but we expect the outcomes with FLEx will become more precise as the technique is refined, and this approach would have the advantage of eliminating the need for two lasers,” said Dr Blum.

Novel application

The various femtosecond lasers are being used for a number of different indications in corneal surgery. Diverging from that path, Ronald Krueger, MD, US, described research he has been conducting using a femtosecond laser to cause intralenticular photodisruption as a method for restoring accommodation.

The basic concept is to use an ultrashort pulse laser to cause photo-phaco-modulation in order to alter lens elasticity.

“The idea for this procedure is that creating small laser microperforations within the hardened lens nucleus would enhance the sliding of fibres within the lens and thereby increase lens flexure,” he explained.

An early study in cadaver eyes showed that treatment of a lens from a 54-year-old donor with 100 suprathreshold pulses in an annular pattern was associated with increased deformation when submitted to strain. Subsequent studies have focused on identifying the mechanism for that change, identifying the best pattern for the laser treatment, evaluating the potential to induce cataract, and determining what happens to the bubbles created.

So far, animal studies showed the treatment did not cause cataract, alter light scattering, or result in thermal damage into the peripheral lens tissue. Using a finite element model, it was determined that the procedure works because of sliding fibres within the lens and that layered shells are the best potential pattern so far. With the use of lens tissue cultures, it was seen that the bubbles disappear, and using an instrument to evaluate relative lens resistance to displacement with gradient steps of applied compression force, the results achieved were seen to be repeatable. These data are now being used to determine the parameters for achieving an accommodative effect.

“So far, our studies show accommodation restoration with intralenticular femtosecond lens treatment is theoretically possible and experimentally feasible. With sufficient clinical efficacy, laser lens modulation could become a new strategy in the quest for presbyopic correction,” Dr Krueger said.

More Info-----

For more information on femtosecond lasers in the clinic, listen to a EuroTimes podcast with Michael Knorz MD.

Medical journals join the 21st Century at WOC

In a time of instant messaging, online interaction, and easy access to information online, medical journals often seem soooo last century. EuroTimes listened in on a session given at the World Forum of Ophthalmological Journal Editors in which editors discussed issues they face in the 21st century.

Open-access publishing

Cost issues, commercial influence scandals, and a call for public access to government-funded studies all helped create demand for new models of peer-reviewed medical information delivery. In particular Biomedcentral and the Public Library of Science have quickly gained support and have forced traditional journals to re-evaluate their methods.

However, the concept of what should be open access in the medical field is controversial because while it offers advantages, it can also result in a variety of threats, said Thomas J Liesegang MD, editor-in-chief, American Journal of Ophthalmology.

Quality of content and its interpretation are two major concerns about open access.

“Access to information is crucial to the health and economic wellness of people in all countries, but I maintain that health information is not the same as other information on the web. It needs to be vetted and I also maintain the average consumer does not have the skill to discern good from bad science,” Dr Liesegang said.

There is also the concern that historical scientific literature may be lost as there may not be enough resources to support both traditional and open-access systems simultaneously and continuously. Some journals may not be able to afford to appear in open access and the result could be the termination of small non-profit scientific journals or societies, Dr Liesegang explained.

Open access can be supported by a pay-to-publish model. However, some authors, especially in developing countries, cannot afford the fees, and institutions will have to decide which researchers to support. The result may be that journals become filled with articles supported by commercial interests.

Quality of research published is another issue as some start-up journals in need of material may be willing to accept any manuscript.

“The old subscription-based model has worked well and should not be abandoned until another form of communication is vetted and proven successful,” Dr Liesegang said.

EuroTimes looked at these issues in an earlier article,
Click to read article.

Evidence-based medicine

Randomised clinical trials are considered the gold standard of medical knowledge, and yet the high costs of developing this evidence-based medicine are making it affordable only to multinational drug and device company sponsors, said Francesco Bandello MD, Chinese Journal of Ophthalmology.

The result is a potential for publication of biased and misleading information. And even when the study is high quality, questions remain about how far and to which populations the results can be generalised.

Dr Bandello acknowledged he has no answers to the existing issues. He proposed it may be useful to have trials conceived, designed, and planned by physicians and sponsored by public, independent bodies. Importantly, it is also critical that trials with negative results be published.

“Perhaps we need to pay greater attention to small, smart, independent studies and to focus more on the substance of the research and not just the methods,” he said.

Citation analysis

Citation analysis methods assume more influential articles are cited more often, and these data are being widely used in research environments and by institutions. However, the information can be misleading, said Charles McGhee MD, PhD, editor, Clinical & Experimental Ophthalmology.

Dr McGhee discussed how the perception created by such statistics as citation counts and journal impact factor can differ from reality, and he also reviewed a new parameter – the H factor and provided an example to show it can be misconstrued when comparing two authors.

“The sole reliance on citation data provides at best an incomplete and often shallow understanding of research, an understanding that is only valid when reinforced by other judgments. Numbers are not superior to sound judgment,” said Dr McGhee.

Clinical trial registration

Andrew Schachat MD, editor-in-chief, Ophthalmology, discussed registration of clinical trials, noting that this issue gained attention due to concerns about publication bias favouring clinical trials with positive results. The idea behind registration is to get all trials out into the public record and it is required by all International Committee of Medical Journal Editors' member journals.

While three years ago registration was the exception; it is now becoming the rule. This is a change for the better. However, there is still room for improvement, said Dr Schachat.

“Registration facilitates the dissemination of information among clinicians, researchers, and patients. It also helps to assure trial participants that the information accrued as a result of their altruism will become part of the public record. However, key challenges remain, including problems with duplicate registrations and a need for better search engines,” he noted.

Reviewer issues

For peer-reviewed journals, the present system an editor uses to decide whether a submitted manuscript should be accepted, revised, or rejected depends on his or her review of comments provided by two or three reviewers who are “experts” in the field and anonymous to the author(s). However, problems plaguing this system have driven interest in an open system of review where the reviewers’ identity is made known to the author(s).

“The open system seems to make more sense because it would level the playing field and result in a review that is fair, just and constructive. However, it may be more difficult to find reviewers, and those who accept may tend to be less critical, resulting in higher acceptance rates for already overburdened journals,” said Arun Singh MD, editor, British Journal of Ophthalmology.

Studies evaluating open systems show these fears are well founded, and Dr Singh noted that while reviewers for papers submitted to the British Journal of Ophthalmology are offered the option for open review, only 15 per cent accept.

“We must move towards an open system of review, and newer technology, like Internet blogs, may make this easier. While we are not there yet, I think we may get there sooner than some think,” he said.

Continuing with the topic of reviewers, Alexander Brucker MD, editor-in-chief, Retina, discussed the challenges and opportunities for their selection that have emerged in the computer age. While the number of manuscripts being submitted to journals has increased thanks to the ease of online submission and recent growth in the number of journals, the number of reviewers has not kept pace with the demand, Dr Brucker said.

On the positive side, the Internet has made it easier to identify and contact potential reviewers, and it has also facilitated the reviewing task itself. However, potential reviewers receiving an email message soliciting their cooperation are also finding it easier to refuse by simply selecting the “decline” button, noted Dr Brucker.

“These are exciting times for medical journal editors. We face a number of challenges, but also have opportunities to seize that can result in an improved final product that is better for our consumers,” he said.

WOC debates the future of refractive surgery

The World Ophthalmology Congress (WOC) got rolling in earnest with a number of sub-specialty sessions. We report from the Cataract and Refractive Surgery programme.

Seven well-known researchers offered their prognostications for what refractive surgery might look like in 2020.

Luis Ruiz MD, a true LASIK pioneer, described a new procedure he has developed which promised to dramatically alter the treatment of presbyopia. The technique, which he calls intraCOR, provides flapless intrastromal ablation using the Femtec femtosecond laser (20/10 Perfect Vision) to achieve reshaping of the cornea without touching epithelium, endothelium, Bowman’s membrane, or Descemet’s membrane.

Compared with existing refractive surgery techniques, intraCOR has multiple advantages that include simplicity, speed and safety. The procedure would avoid complications related to flap ablation and surface ablation, can be performed in thin corneas, does not weaken corneal biomechanics nor induce dry eye, and has a reduced risk of infection.

Dr Ruiz has experience with intraCOR in more than 700 patients who have been treated for presbyopia, myopia, hyperopia and astigmatism using customised patterns. Although this new procedure is still being refined, he presented results from a study of presbyopia treatment that included 45 eyes treated with an identical ablation protocol. All had at least one month of follow-up with a range up to six months. Simultaneous UCVA distance and near results showed 100 per cent of eyes achieved 20/25 or better and J2 or better. At three months no patient had lost even one line of distance best corrected visual acuity. Contrast sensitivity was improved in both photopic and mesopic conditions.

Safety data are encouraging – hysteresis was increased, the corneal resistance factor was unchanged, and there were no changes in endothelial cell density or corneal thickness.

“It would be difficult to find an easier or more effective procedure, and in my experience with refractive surgery for presbyopia, I have never seen such amazing safety and quality of vision,” said Dr Ruiz.

The wavefront data provide an explanation for the outstanding results and reveal the treatment results in a true multifocal corneal with a decrease of defocus that results in a myopic shift and an increase in spherical aberration yielding increased depth of field.

Dr Ruiz concluded his talk by acknowledging the need for further studies, but Jorge Alio MD, PhD, chairman of the session commented that if the promising outcomes being achieved with this important innovation are confirmed in subsequent research, it will completely change the way refractive surgeons approach the treatment of presbyopia.

Myopia prevention

Donald Tan MD, Singapore, discussed prevention of myopia progression in schoolchildren using a treatment called Neurovision. This approach is particularly relevant in Singapore where myopia progression in children occurs at a rate of about 100 degrees per year so that by age 18, about 80 per cent of Singaporeans are myopic.

“As myopia progresses in young children, their spectacles fail to keep up with the progression rate and visual acuity is suboptimal. Neurovision aims to enhance visual acuity without changing the refraction so that theoretically, visual acuity can be shifted toward a more normal level. And, maybe if we are successful in preventing myopia evolution, we will not need to perform so much refractive surgery in the future,” he said.

The approach involves a computerised, Internet-based program that uses visual stimuli to optimise image processing by the visual cortex, enhancing contrast sensitivity by neural adaptation and repetitive visual memory exercise to result in enhanced visual acuity. The exercises use a visual psychophysics tool and are performed every other day for a total of 30 sessions.

More than 1,300 patients have been treated with the Neurovision approach to date both in clinical trials and commercially. Patients have included mild myopes, children and adults with amblyopia, presbyopes, post-refractive surgery patients, and people with high functional visual demands aiming for sharper vision. Results have been published in the literature showing consistently that patients gain more than two lines of ETDRS visual acuity and maintain a majority of the benefit after 12to 18 months.

Its efficacy in reducing myopia progression in schoolchildren was evaluated in a pilot study that had a prospective non-comparative design. Thirty children ages seven to nine years performed the sessions using a treatment adapted to a computer game and were followed for 18 months after completing the program.

The results were consistent with other studies in showing a mean improvement of logMAR visual acuity of about 2.2 lines along with improvement in contrast sensitivity that enabled the children to wear spectacle undercorrection and still get good vision.

“This may be the first effective treatment modality to reduce myopia progression in children without medical or surgical treatment. The results of this pilot study provide the basis for a large-scale, placebo-controlled randomised clinical trial that will be launched in four schools this year,” said Dr Tan.

Ultra-thin corneal inlays

Placement of a corneal inlay represents another approach under investigation for the treatment of presbyopia. Relative to some other techniques, it has a major advantage of being reversible and exchangeable, said Perry Binder MD, US.

Dr Binder discussed the ACI 7000 (AcuFocus) corneal inlay, a small, ultra-thin device placed within a pocket that works via a pinhole effect to increase depth of focus. The goal of this procedure is to create less of a blurred image on the retina up close without interfering with distance vision. The surgery takes just five minutes and cosmesis is excellent.

Almost 400 eyes have been implanted with this inlay and up to three years of follow-up is available. Results show no change in distance uncorrected visual acuity but a significant improvement in near vision with most eyes achieving J1 or better. Similarly positive results are being achieved in a smaller series of patients who have received a thinner model inlay (5 vs 10 microns thick).

“Lots of questions need to be answered, including what is the best material to use, what is the best method to centre the device, and should it be placed through a flap or pocket. However, we have found patients are happy and achieve the benefit of a +1.5 D lens without handicapping their distance visual acuity,” Dr Binder said.

Considering that it takes 10 to 12 years between the time an investigational IOL is first implanted in human eyes and then achieves approval by the US FDA, David F Chang, MD, US, reviewed four accommodating IOLs that have the potential to be available in 2020 because they have already entered clinical trials.

Accommodative IOLs

The Synchrony dual optic accommodating IOL (Visiogen) combines a +32 D moving front optic with a posterior optic of variable minus power based on the individual patient’s needs. It is a silicone, bag-filling IOL that comes pre-loaded in an injector system for delivery through a small incision. The implant is designed to work according to the Helmholtz theory and delivers +2 to +2.5 D of accommodation.

A Phase III US FDA trial including 475 eyes was completed in November 2007. While data are not available from that study, Ivan Ossma, MD, has reported a randomised clinical trial comparing the dual optic accommodating IOL with the ReSTOR multifocal IOL (Alcon Laboratories) in 100 patients. Its results favoured the dual optic IOL for better intermediate vision, contrast sensitivity, reading speed, and problems with haloes. High-definition UBM studies confirm movement of the anterior optic, said Dr David Chang.

Two shape-changing lenses (NuLens, Power Vision) have the potential to provide +8 to +10 D of accommodation. The NuLens features a deformable substance between two rigid plates that is pushed forward through a small aperture by ciliary muscle contraction to create a change in lens curvature. The anticipated commercial design will consist of a haptic unit and a base unit assembled inside the eye.

Jorge Alio MD, PhD, has conducted a pilot trial in 10 blind eyes with BSCVA of 20/200or worse and showed attainment of up to +10 D of accommodation that provided enough magnification so patients could read large print.

The Power Vision accommodating IOL is based on movement of fluid from a reservoir and has been evaluated in five blind eyes. Proof of concept has been demonstrated by anterior segment OCT imaging after pharmacological stimulation of accommodation.

Based on the unexpected finding that a patient implanted with the Light Adjustable Lens (Calhoun Vision) achieved J1 reading vision after treatment for residual myopia, this platform is also being considered as a presbyopia-correcting lens. The algorithm would involve creation of an aspheric design that is gradually sloping off into the periphery with a blend, like a Varilux lens, to create a multifocal lens without discrete rings.

“This approach would reduce problems with glare or haloes and would simultaneously allow guaranteed treatment of residual sphere and cylinder,” Dr Chang said.

Future directions in science, and marketing

Ioannis Pallikaris MD, PhD, Crete, discussed the emerging field of “Presby-optics”. He described evolving knowledge of the underlying physiology of presbyopia that has developed as a result of improved technology for studying the dynamic accommodative process.

“Understanding Presby-optics is about merging this basic knowledge and clinical experience and then applying it to identify the best overall solution for each patient,” he said.

Richard Lindstrom MD, US, concluded the session by providing his thoughts on the future directions for market growth in IOLs for presbyopia correction. Currently, monofocal implants account for 95 per cent of the pseudophakic market with multifocal IOLs accounting for four per cent and the remaining one per cent represented by accommodating IOLs. Looking ahead, Dr Lindstrom expects to see a significant market share shift as monofocal IOLs undergo a steady decline, multifocoal IOLs enjoy an initial surge but then disappear completely, and accommodating IOLs enjoy increasing growth to account for 20 per cent of implants by the year 2020.

“While revenue growth in the cataract IOL market has been occurring at a rate of about three per cent a year, 59 per cent of the growth in IOL revenue in 2006 came from presbyopia-correcting lenses. I expect we will continue to be seeing these new growth patterns into the future. However, surgeons should also remember that monovision with monofocal IOLs remains a popular option that should be offered to patients,” Dr Lindstrom said.

Dr Lindstrom is not alone in his belief that multifocal IOLs are the future of presbyopia-correcting implants. In the 2007 survey of ASCRS members, 76 per cent of respondents said they would favour an accommodating IOL for themselves if they had a presbyopia-correcting lens.

There is also clinical trial evidence that accommodating IOLs can generate satisfactory objective and subjective patient outcomes when used symmetrically or asymmetrically with other types of implants. His outlook for an advance in accommodating IOL market share is also based on the promise of IOLs in development that can provide a greater range of accommodative amplitude.

Dr John Chang appointed medical editor of EuroTimes China at WOC in Hong Kong

Dr John Chang has been appointed medical editor of EuroTimes China. Dr Chang, who takes up his position from today, June 27, will have responsibility for the editorial content of the magazine working with the newly appointed Editorial Board of EuroTimes China.

The appointment was announced to coincide with the WOC meeting in Hong Kong.

“We are delighted to invite Dr Chang to join our editorial team," said Dr Emanuel Rosen, chairman of the International Editorial Board of EuroTimes. “EuroTimes China is published by the ESCRS and offers Chinese ophthalmologists a forum for discussion, learning and the development of global ophthalmology,” said Dr Rosen.

“EuroTimes China has now reached 8,000 circulation and is still growing and we are confident that with Dr Chang’s guidance we will enhance the communication between the European and Chinese ophthalmologists,” he said.

Dr Chang said he was honoured to accept the position. “EuroTimes China is highly regarded in the ophthalmological community, and I hope to build on its growing reputation, working closely with the ophthalmologists of great talent, influence and learning on the EuroTimes China editorial board,” said Dr Chang.

The members of the Editorial Board of EuroTimes China are:

Dr Yansheng Hao, Dr Ningli Wang, Dr Ying Li, Dr Yuegou Chen, Dr Haike Guo, Dr Yizhi Liu, Dr Jian Ge, Dr Zheng Wang, Dr Dong Fangtian, Dr Xiaoxin Li, Dr Chenjin Jin, Dr Gezhi Xu,Dr Xun Xu, Dr Peiquan Zhao, Dr Zhenping Huan, Dr Jinsong Zhang, Dr Yi Lu, Dr Zinghuai Sun, Dr Jingcai Lian, Dr Xingtao Zhou, Dr Kanxing Zhao, Dr Yan Wang, Dr Ke Yao, Dr Ye Shen, Dr Qinmei Wang, Dr Yaohua Sheng, and Dr Yuehua Zhou.


For more information contact Mr Colin Kerr, executive editor of EuroTimes, at 00 353 86 0473478.

ESCRS symposia at WOC in Hong Kong

The ESCRS is hosting two symposia at the World Ophthalmology Congress in Hong Kong, which runs from 28 June until 2 July.
On Sunday 29 June, from 9am to 10.30am, Paul Rosen will chair a session on The Cutting Edge of Cataract Surgery. This will be followed on Sunday afternoon from 4pm to 5pm with a discussion on IOL Based Refractive Surgery chaired by Ioannis Pallikaris.

The full timetable is:

Sunday 29 June

09.00 – 10.30
The Cutting Edge of Cataract Surgery
Chairperson: Paul Rosen UK

09.00 Charlotta Zetterstrom Norway
Paediatric cataract surgery

09.10 Marie-Jose Tassignon Belgium
Bag-in-the-lens in a child’s eye

09.20 Peter Barry Ireland
ESCRS Endophthalmitis Study – further results

09.30 Clive Peckar UK
Toric IOLs

09.40 Richard Packard UK
Phacodynamics

09.50 Gerd Auffarth Germany
Multifocal IOLs

10.00 Jorge Alio Spain
Quality of incision in cataract surgery

10.10 Ioannis Pallikaris Greece
Apodized versus aspheric multifocal IOLs

10.20 Discussion

10.30 End of session
..........

Sunday 29 June

16.00 – 17.30
IOL Based Refractive Surgery
Chairperson: Ioannis Pallikaris Greece

16.00 Ioannis Pallikaris Greece
Introduction

16.08 Klaus Ditzen Germany
Overview of different IOLs in refractive surgery

16.16 Jose Guell Spain
Veryflex Phakic IOL and LAL Light Adjustable Lens: Two years' follow-up

16.24 Joseph Colin France
Update on anterior chamber and posterior chamber IOLs

16.32 Camille Budo Belgium
Artiflex lens

16.40 Michael Knorz Germany
Keys to LASIK in monofocal and multifocal pseudophakes

16.48 Matteo Piovella Italy
Nine pearls to improve outcome in advanced multifocal IOL implantation

16.56 Rudy Nuijts Netherlands
Astigmatism management in cataract surgery with Toric Intraocular Lenses

17.04 Manfred Tetz Germany
Refractive Lens Exchange: Short and long term results

17.12 Discussion

17.30 End of session

EURETINA gets ready for Nice

The success of the 8th EURETINA Congress in Vienna will inspire the organisers of next year's conference in Nice, France, to host an even bigger and better conference.

That is the view of EURETINA president Dr Jose Cunha Vaz. "The challenge is always to produce a better conference next year," Dr Cunha Vaz told EuroTimes. "One of the most notable aspects of this year's conference has been the attendance of a large number of younger retina specialists and I am very encouraged by that," he said.

The 9th EURETINA Congress will be held in the Nice Acropolis Centre from 14 May to 17May 2009.

EuroTimes will be providing regular updates on EURETINA in the future so watch this space.

Austrian ophthalmologists honoured to host EURETINA Congress in Vienna

By Dermot McGrath

As the celebrated crossroads of Europe, Vienna provides the perfect backdrop for this year's gathering of clinicians and researchers interested in the research and treatment of retinal and macular diseases.

Speaking on behalf of the Austrian Ophthalmological Society (ÖOG) at the opening ceremony, Susanne Binder MD, the current president of AOS, said that her organisation was honoured that the EURETINA Congress was taking place in Vienna. She noted that attendance at the annual congress is increasing each year with over 1,500 delegates from 74 countries attending this year's event.

Dr Binder noted that the ÖOG has a long and rich history and some of the most famous names in ophthalmology have been counted among its ranks. The society was officially founded in 1954, with Prof Dr Anton Pillat, head of the First University Eye Clinic in Vienna, serving as its first president.

Among some of the pioneers in retinal research who have close associations with Vienna, Dr Binder cited Georg Joseph Beer who gave the first clinical description of a detached retina in 1817, Karl Lindner who helped to popularise scleral resections in the 1930s after Muller had introduced it in 1903, and Karl Hruby who made great advances in retinal detachment surgery.

More recently, Dr Binder said that people such as Heinz Freyler, Hans Gottinger, Ursula Schmidt-Erfurth, Andreas Wedrich and Nikolaos Bechrakis, were continuing Austria's proud tradition in the field of retinal research.

Turning to the aims of the ÖOG, Dr Binder said that the organisation has continued to evolve since its foundation in 1954 and is continually seeking to better serve the needs of its members.

“Our organisation provides information and exchange about the latest research and state-of-the-art treatments, organises continuing education, licenses examinations, sets guidelines for therapies and defends the interests of its 930 members. We are also building greater links with other ophthalmological organisations and have recently joined the European Board of Ophthalmology, and the Vision 20/20 programme in order to improve our international education and training,” she said.

The ÖOG holds its own three-day meeting every year, usually in May or June, which is designed to showcase state-of-the-art treatments as well as the latest developments in research and clinical practice. The organisation also has its own scientific journal Spektrum für Augenheilkunde, which publishes a wide range of articles on all aspects of ophthalmology as well as reports of the society's meetings.
In her concluding remarks, Dr Binder thanked the ophthalmic industry for its ongoing support of the EURETINA Congress and said she looked forward to seeing even more delegates at next year's gathering in Nice, France.

1,500 retina specialists attend 8th EURETINA Congress in Vienna, Austria

More than 1,500 delegates have registered to attend the 8th EURETINA Congress in Vienna.

Over the past years EURETINA has grown and expanded its activities. Attendance at the annual congress is increasing each year with 973 delegates from 63 countries attending the 2007 EURETINA Congress in Monte Carlo.

The increase in the number of delegates at the 2008 Congress reflects the growing importance of EURETINA as an organisation but also the strength of the scientific programme at the Congress.

The European Society of Retina Specialists (EURETINA) is an organisation comprising clinicians, scientists and researchers interested in treating macular and vitreoretinal diseases. It was founded as a non-profit organisation in 2000.

Over the next few days, the EuroTimes weblog will feature some of the highlights from the programme and some of the messages from the key speakers attending the congress.

We welcome the views and opinions of EuroTimes readers and delegates attending this year's congress, so please feel free to comment on any matter of interest to you.

Jose Cunha-Vaz

EURETINA president

EURETINA goes from strength to strength

EURETINA is celebrating its eighth year in existence with the Vienna meeting. There is a lot to be proud of and this organisation is going from strength to strength.

From what started as a small special-interest group a few years back, EURETINA has evolved into a truly international organisation.

There is no room for complacency and there are always ways in which things can be improved, so we’ll certainly be looking to build on this foundation in the years ahead.

There are several reasons for the growing success of the organisation. Firstly, there is the high quality of the congress itself, which has improved tremendously over the past three years. We are continually looking for new ways to make the experience even better for the delegates. For instance, the introduction of surgical-skills courses is attracting great interest. Furthermore, the scientific programme is of a very high standard and there is a broad range of topics to reflect the latest developments in the field.

It is also vital to stress that while we have excellent participation from the ophthalmic industry, with a first-rate exhibition and many sponsored symposia and so forth, the meeting is not industry-driven and has maintained its reputation for scientific credibility and independence. Another factor is that it is not only retinal specialists who are attending the meeting. Intravitreal injection has opened the door to a lot of new therapies and even general ophthalmologists are beginning to get very interested in the possibilities of these treatments. All of these factors together are helping to increase interest and helping the organisation to expand rapidly.

EURETINA has helped to fill an obvious gap in Europe by bringing retinal clinicians together in the region. After all, Europe is expanding at a rapid rate and it is particularly encouraging to see so many new colleagues joining from eastern Europe, now that the door has been opened to them to attend this kind of meeting. There is also a great thirst for knowledge and innovation in many of the new European Member States and I think that is helping to drive the interest in EURETINA as well.

* Jose Cunha-Vaz, president of EURETINA,in an interview with Dermot McGrath. The full interview will be published in the special EUROTIMES EURETINA Daily supplement which will be published on Saturday May 24th

EuroTimes to post daily EURETINA weblogs

I will be in Vienna with EuroTimes' contributing editor Dermot McGrath posting daily weblogs from the 8th EURETINA Congress. If you wish to comment or leave suggestions for articles, please feel free to do so.

Dr James MacCallum: Canadian ophthalmologist and friend of the Group of Seven

The XXVI Congress of the European Society of Cataract and Refractive Surgeons will be held in Berlin from September 13 to September 17.

In recent issues of EuroTimes, we have looked forward to the Berlin congress by profiling some of the great German philosophers who have shaped the future of ophthalmology including Goethe and Helmholtz.

Dr James MacCallum (1860-1943 does not fit automatically into this category but his influence on the arts merits a closer look at his life and career.

MacMCallum is indelibly linked to the work of The Group of Seven, a group of Canadian landscape painters in the 1920s, originally consisting of Franklin Carmichael, Lawren Harris, A Y Jackson, Frank Johnston, Arthur Lismer, J E H MacDonald, and Frederick Varley.

Tom Thomson (who died in 1917) and Emily Carr were also closely associated with the Group of Seven, though neither were ever official members. The Group of Seven is most famous for its paintings of the Canadian landscape. It was succeeded by the Canadian Group of Painters in the 1930s.

I was lucky to see some of the Group of Seven’s work when I recently visited The McMichael Canadian Art Collection in Kleinburg, an idyllic rural setting, approximately 30 kilometres northwest of downtown Toronto.

Of 10 artists who were members of the Group of Seven, six are buried in a small cemetery on the McMichael grounds: Arthur Lismer, Frederick Varley, Lawren Harris, Frank Johnston, AJ Casson and A Y Jackson.

MacCallum was friend, patron and mentor to the Group of Seven and without his financial support, they would not have enjoyed the influence they do today. He was particularly close to Lawren Harris who studied in Berlin from 1904 to 1907.
His time in Berlin may have helped Harris learn his craft as an artist but it also may have reinforced his deep love of the Canadian landscape which was reflected in his subsequent work on his return to Canada.

Harris shared his love of the Canadian wilderness with MacCallum who promoted the Group of Seven by buying their work and also by encouraging others to do so.

In an essay in the Canadian Medical Association Journal (CMAJ) “Dr James MacCallum: patron and friend of Canada’s Group of Seven” (Can Med Assoc J 1996;155: 1333-5) Roger Burford Mason, notes that MacCallum’s keen delight in painting and in helping artists, expanded the borders of Canadian art.

MacCallum received a BA from the University of Toronto in 1881 and also spent two years studying in Moorefield’s Hospital in London, England before returning to Toronto in 1888 where he spent the next 50 years as one of Toronto’s most respected ophthalmologists.

In a letter to the CMAJ, Dr Graham E Trope, MB professor and head of the University of Toronto and ophthalmologist-in-chief of The Toronto Hospital points out that while he has been rightly honoured for his contribution to the development of Canadian art, in his time, MacCallum was also considered the most outstanding ophthalmologist in Ontario.

He was professor of ophthalmology at the University of Toronto from 1914 to 1929, published widely on ophthalmologic conditions and represented the university on the council of the College of Physicians and Surgeons of Ontario.

And that is where it ends for now, but I'd be glad to hear from any readers of this weblog who have more information on James MacCallum.



References:

Thanks to Mike Keenan whose website whattravelwriterssay.com/kleinburgontario has excellent information on Kleinburg.

The information on Dr James MacCallum is sourced from the website of the Canadian Medical Arts Journal at: cmaj.ca, and from Roger Burford Mason’s article: “Dr James MacCallum: patron and friend of Canada’s Group of Seven” (Can Med Assoc J 1996;155:
1333-5).

EuroTimes in Toronto

I'm just back from a week's holiday in the beautiful city of Toronto.

For any doctors or ophthalmologists who are interested in intelligent radio programmes about medicine, check out an excellent series on Canadian radio called White Coat, Black Arts.

The link is www.cbc.ca/whitecoat/2008