World Ophthalmology News World Ophthalmology Congress 2012 | 16 – 20 February | Abu Dhabi

Tackling ROP Therapies for AMD Tears and Bubbles The KIDROP-experience shows that Noumerous new medical therapies for Femtosecond laser flap complications tele-ophthalmology is a cost effective wet age-related macular degeneration are very rare and often linked to the possibility to spread ROP-screening are under investigation. This is one of surgical technique. Usually they can programmes into the ural areas of the most rapidly evolving fields in oph- be handled without consequences for India. ( Page 3 thalmology. ( Page 8 the patient. ( Page 11

An Enriching Experience The World Ophthalmology Congress 2012 in Abu Dhabi: Outstanding Speakers, Ultra-Modern Exhibition Centre, Traditional Hospitality

ABU DHABI [jp] – For the first time the heritage, Abu Dhabi promises to be an World Ophthalmology Congress (WOC) ideal setting for scientific communi- will be hosted in the Middle East and cation and innovation.” Africa Region. See, Hear and Taste the Culture he destination is definitely new The local organizers as well as repre- to most of the participants of sentatives of the Abu Dhabi Tourism T ophthalmic congresses: Abu Authority also recognize the congress Dhabi, the capital of the United Arab as an opportunity to present the Emirates (UAE) will be the heart of the capital of the United Arab Emirates ophthalmic world from 16 to 20 and the wider emirate to a worldwide February 2012. Never before such a audience. Members of the Middle East prestigious international medical Africa Council of Ophthalmology meeting has taken place in the Middle (MEACO) strive to ensure that all WOC East and Africa Region. visitors experience a stimulation envi- ronment. Prince Abdulaziz Ahmed Another World-Class Congress Abdulaziz Al Saud, chairman of the

Dr. Abdulaziz AlRajhi, this year’s ADNEC MEACO board, promises culturally congress president, is confident, that The heart of the ophthalmic world from 16 to 20 February: The Abu Dhabi National Exhibition Center rich social events: “You will see, hear the WOC 2012 “will prove to be an and taste the unique Arabian culture.” enriching experience to all the parti- E. Spivey, president of the Interna- areas. More than 45 sessions will be topic. Leading ophthalmologists cipants and delegates”. High quality tional Council of Ophthalmology is organized by the International Council around the world will coordinate, Luxury and Style scientific content from more than sure: “You can expect another world- of Ophthalmology members and par- moderate oder chair the sessions. A great opportunity to do so will be 2000 internationally recognized class congress, matching those in Ber- ticipating societies. Symposia, case the cultural night on 17 February at speakers, a rapidly evolving city with lin, Hong Kong and Sao Paulo.” studies, debates, panel discussions, Ideal Setting the Abu Dhabi Emirates Palace: an ultra modern exhibition centre Chairman of the scientific pro- video sessions and interactive lectures Wiedemann encourages the Luxury and style, infused with tradi- and the unique Arab culture: These gramme is Prof. Dr. Peter Wiedemann will give every congress attendee the colleagues from all over the world to tional values of hospitality and respect are the elements that will contribute who coordinates a programme that possibility to gain insight into the attend the WOC 2012: “A modern city will be the source of a memorable to a high standard congress. Dr. Bruce will cover 35 subspecialty and topic latest developments in their respecitve combined with a rich cultural experience. W

Dealing with Small Pupils Mechanical Stretch, Iris Hooks, Malyugin Ring

SUNDERLAND – The definition of a small losin use, or it may simply be a small of 1 minim of 2.5% phenylephrine ensure that your incisions in the pupil depends on the degree of ex- pupil. (Bausch & Lomb) added to 1-2 mL of cornea to place the hooks are very perience of the surgeon, and also on the Always check to see if there are BSS injected into the AC can give peripheral (there should be bleeding at degree of surgical difficulty expected to posterior synechiae and carefully added dilatation, and certainly dimi- each incision) and horizontal (figure be encountered. break these (including at mid-stroma nishes or prevents re-constriction and 2). This ensures that you are pulling if patient has been on long term also prevents iris prolapse. the pupil margin peripherally rather n experienced surgeon may miotic). In all cases consider reducing your than upwards. be happy to operate with a Simple mechanical pupil stretch fluidics parameters. A high aspiration Some hooks come in packs of 5 – A 3-4 mm pupil in a straight- with 2 instruments can be effective in flow rate increases the risk that you the 5th one is meant as a ‘spare’ in forward case, but may be unhappy many cases (figure 1). It is important will aspirate the pupil margin in small case you drop one. However, you can with a 4.5 mm pupil if dealing with a to stretch by taking the instruments pupil cases. A high vacuum then also plan to use 5. When using 4 make rock hard cataract. The problems almost into the angle. One problem is makes it much more likely that you a ‘diamond’ pattern rather than a caused by a small pupil are not con- David Allen that the pupil may then re-constrict or will damage the iris tissue if you do ‘square’ – in other words one hook fined to difficulties removing the wave in the breeze because of multiple catch it, and this can cause problems should be placed under the incision so nucleus without damaging the iris Small pupils may be due to poste- sphincter rupture. for the surgery and problems for the that you get maximum retraction margin. A smaller pupil allows less rior synechiae from previous inflam- Experience with IFIS from tamsu- patient afterwards. where you are entering the eye with light to enter the eye, and so the red mation or previous miotic use (rare losin use has shown the value of intra- For some cases it is desirable to the phaco tip (figure 3). Try to space reflex may be poorer with smaller now but was common in the past). The cameral alpha agonists either at the mechanically dilate and then in some the incisions/hooks as symmetrically pupils and the threshold for use of a condition may in other cases be due to outset or during surgery. We favour way to fix the pupil. We initially as possible. capsule staining dye is therefore some other concurrent disease/medi- phenylephrine diluted in BSS (others learned from vitreo-retinal surgeons lowered. cation e.g. pseudoexfoliation, tamsu- advocate epinephrine). The contents to use iris hooks. If you use iris hooks continued on page 2 ( 2 | woc 2012 World Ophthalmology News | 2012

( continued from page 1 use than hooks – although it is not without its difficulties. In all cases More recently a very simple but where the pupil has been stretched Current Status of Phakic IOL ingenious device from Russia consider using additional anti-inflam- (Malyugin ring) has become very matory medication post operatively to Doubts are Justified – but New Lenses Arouse Expectations popular. Personally I find this easier to reduce the chances of uveitis/fibrin. FRANKFURT – Endothelial cell loss or in the development of different PIOLs, The weak point of iris-fixated PIOL is Further Notes on the iatrogenic cataract discourage many are still appropriate when modern the endothelial cell loss. Studies show Particular Problems of IFIS surgeons from using phakic lenses. New, PIOL are used? The answer is yes. And mean rates of up to a maximum of At the turn of the year 2004/05 we modern PIOL may offer new solutions to no. Doubts are justified, but the nega- 14.05% after 5 years.4 Outliers, how- became aware of a ‘new’ phenomenon their questions. tive experiences with former implants ever, also need to be taken into con- – the intra-operative floppy iris syn- are not 100% applicable to today’s sideration. drome (IFIS). While the exact mecha- rials comparing corneal refrac- lenses. The history of anterior chamber nism underlying this problem is still tive surgery with phakic The most dreaded complication of angle-supported PIOL is mainly a histo- uncertain, we do know that it is rela- T intraocular lenses (PIOL) reveal posterior chamber PIOL is iatrogenic ry of failures. Even though visual results tively common. The biggest risk factor the superiority of the latter in terms of cataract, induced by contact between have been very good, severe endothelial for IFIS is the current or previous use quality of vision, while other para- the PIOL and the natural lens due to cell losses, pupil ovalizations, synechia Figure 1: Use of two instruments to stretch of the drug tamsulosin. 1-2% of the meters like stability, safety and effi- insufficient vaulting and/or modified and inflammations have led to the with- a small pupil. Note, stretch out almost into cataract surgery population is in this aqueous humour fluidics. Schmi- drawal of almost every implant.3,4 The the AC angle. category. Although some surgeons dinger et al5 show a nearly linear and latest development in this field is the have been concerned about patients continuous decrease in the distance of Cachet PIOL (Alcon, figure 3), a single- taking other α1a blocking agents, the the ICL V4 (STAAR) and the natural piece, foldable soft acrylic IOL. Visual risk of experiencing IFIS in patients lens in 84 patients. From 466±218 µm results are very good, as published with tamsulosin is 40 times that in directly after surgery the distance three-year FDA trial data by Knorz et al7 patients using other blockers. decreases to 184±159 µm after show. For example: UDVA was 20/40 or These are not simply patients with 74.1±23.1 months. The resulting better in 101 (97.1%) and 20/20 or bet- small pupils. The iris behaviour is quite clinical significant anterior subcap- ter in 48 (46.2%) of 104 patients. The specific, and some simple measures sular cataract rate in their retro­ residual refractive error was good for ‘normal’ small pupils such as spective trial cohort was 28% after 44 within ±0.50 D of target in 82 patients pupil stretching are positively months. 17% of the patients under- (78.8%). contraindicated in IFIS patients. went explantation of the PIOL follow- Apart from that, all other known ing cataract surgery. Inadequate clear- severe complications from angle- Our Experience of IFIS ance between the natural lens and the supported anterior chamber lenses Experience with 30 consecutive eyes PIOL was a significant predictor for seem to be under control. No pupil Figure 2: Placing peripheral corneal inci- in late 2005/early 2006 in patients anterior subcapsular cataract forma- ovalization, pupillary block, or retinal sions for iris hooks. Note, three incisions taking Tamsulosin: tion. The latest design evaluation of de-tachment was observed after three already made and their position shown by 50% of patients will dilate well, but the ICL provides a central hole in the years.7 Looking particularly at the small amount of bleeding. 50% of these will subsequently con- optic to prevent pupil- endothelial cell loss strict during surgery Figure 1: Slit lamp and UBM imaging of the lary blocking and to data leaves refractive 35% will be moderately dilated ICL (STAAR) with central hole (“aquaport”). enhance the aqueous surgeons optimistic. 15% will be poorly dilated humour fluidics in the The annualized per- Manvikar & Allen JCRS 32:1611-14 gap between the ICL centage loss in central 2006 and the lens to reduce and peripheral cataract formation. endothelial cell density Thu, 16 February 13.00 – 14.30 hrs (Figure 1) First results from 6 months to 3 Hall 10 by Shimizu et al6 show years was 0.41% and Session: CAT - Detour: roadblocks to routine very good short-term 1.11%, respectively.7 phaco visual results, compa- The natural endothelial rable to other phakic cell loss in adults is

( Author: David Allen Aramberri (3) Dr. lenses, proving the Alcon about 0.3 to 0.6%. Consultant Ophthalmologist Figure 2: Iris fixated Artisan lens (Ophthec), optical practicability Figure 3: Cachet phakic angle Both, visual acuity and Figure 3: Iris hooks in ‘diamond’ configur- Sunderland Eye Infirmary 2 years post implantation. of the central hole. supported lens. endothelial cell loss ation allowing maximum dilatation in sub- England Although this is a very numbers, remain stable incisional area. E-Mail: [email protected] cacy are comparable.1,2 However, PIOL promising implant, longer follow ups when looking at the, yet unpublished, today are most often used in patients, are needed to evaluate the cataract 5-year follow up. However, longer fol- for whom refractive corneal surgery is rate and long term vaulting stability. low up is required here as well, to not applicable due to high ametropia, In opposite to this very new poste- evaluate the long-term safety. 10 Pearls for Dealing with IFIS large pupils and thin or irregular rior chamber PIOL, the long-term corneas. Known severe long-term results of today’s most commonly The Ideal Phakic Lens It is seen in 2/3 patients using Tamsu- . 5. Ensure the inner incision edge is complications like the endothelial cell used anterior chamber iris-fixated The ideal phakic lens has to fulfil losin. IFIS with Tamsulosin 40* than anterior to the iris plane. loss or cataracts discourage many PIOL (Artisan, Ophthec, figure 2) are different requirements: Lenses should with other α1 blockers. Also with A smaller phaco-needle bore may help surgeons from using phakic lenses as well known. The visual outcomes are be foldable to allow for astigmatism- hypertension (Odds Ratio 2.2) but not to avoid engaging iris an equal procedure next to laser excellent, even in toric patients. neutral implantation and thus predict- with diabetes . 6. Try to use 0.9/0.8mm (20/21G) refractive surgery.3,4 Sizing of the implants is, contrary to able refractive outcome. Lens design, . 1. Assume there will be IFIS if the phaco needles. The question arises, whether these posterior chamber or angle-supported positioning and material should not patient takes tamsulosin. Some have advocated use of dis- doubts, resulting from many failures anterior chamber IOL, not an issue. induce any short- or long-term . 2. It may affect any patient, there- persive OVD (Viscoat) placed on the intraocular damage; endothelial cell fore you and your staff need to be iris and at pupil edge. Arshinoff has loss and cataract formation are espe- prepared. Some have advocated pre- modified his ‘ultimate soft shell References cially an issue here. If lenses fulfil treatment with Atropine – either on technique’ to create a bridge of dis- these needs, there is no reason, why 1. Vilaseca M, Padilla A, Pujol J, Ondategui JC, Artal P, Guell JL. Optical quality one the day or for 2-3 days prior. This persive OVD in the AC PIOL should not be used as an equal month after verisyse and Veriflex phakic IOL implantation and Zeiss MEL 80 LASIK for disrupts normal routine and is not as . 7. Think about and use the proper- myopia from 5.00 to 16.50 diopters. J Refract Surg 2009;25:689-698. procedure next to corneal laser refrac- effective as intra-cameral phenyle- ties of viscoelastics to assist you. 2. Barsam A, Allan BD. Excimer laser refractive surgery versus phakic intraocular lenses tive surgery. Eventually PIOL have one phrine (IPE) High flow causes turbulence and for the correction of moderate to high myopia. Cochrane Database Syst Rev major advantage compared to excimer 2010:CD007679. . 3. Pre-treating with Atropine is high vacuum causes iris damage if laser surgery: their reversibility! W 3. Guell JL, Morral M, Kook D, Kohnen T. Phakic intraocular lenses part 1: historical over- not advised. Phenylephrine is a potent caught view, current models, selection criteria, and surgical techniques. J Cataract Refract Surg α agonist. Placing this in direct con- . 8. Use moderate or low fluidics 2010;36:1976-1993. Thu, 16 February 16.30 – 18.00 hrs tact with iris tissue appears to produce (recommend 20-30 mL/min, 200- 4. Kohnen T, Kook D, Morral M, Guell JL. Phakic intraocular lenses: part 2: results and Hall 10 the maximum dilator tone. 300 mmHg, 80-90 cm bottle height). complications. J Cataract Refract Surg 2010;36:2168-2194. Session: CAT - Hot topics in cataract surgery . 4. Use appropriately diluted (con- Despite everything, some pupils 5. Schmidinger G, Lackner B, Pieh S, Skorpik C. Long-term changes in posterior chamber phakic intraocular collamer lens vaulting in myopic patients. Ophthalmology tents of 1 minim 2.5% in 1-2mL remain too small for safe phaco. ( Authors: Oliver K. Klaproth, 2010;117:1506-1511. BSS) intracameral phenylephrine . 9. Do NOT stretch small pupils of 6. Shimizu K, Kamiya K, Igarashi A, Shiratani T. Early clinical outcomes of implantation of Thomas Kohnen, MD, PhD, FEBO - ‘prophylactically’ at the outset Tamsulosin patients – use a physical posterior chamber phakic intraocular lens with a central hole (Hole ICL) for moderate to Corresponding Author: Thomas Kohnen, - or if pupil begins to constrict pupil expander, Iris hooks or high myopia. Br J Ophthalmol 2011. Department of Ophthalmology - or if iris begins to prolapse Malyugin ring. 7. Knorz MC, Lane SS, Holland SP. Angle-supported phakic intraocular lens for correction Goethe University of moderate to high myopia: Three-year interim results in international multicenter Incision placement and size are impor- . 10. Remember the other 9 pearls, Frankfurt am Main, Germany studies. J Cataract Refract Surg 2011;37:469-480. tant. particularly number 2. W E-Mail: [email protected] World Ophthalmology News | 2012 woc 2012 | 3

The KIDROP Experience in India Tackling ROP in Middle-Income Countries with Cost-Effective Tele-Ophthalmology

BANGALORE – The need for telemedicine images to be viewed on the smart study to complete an economic eva- matrix. These ranks measured the lic private joint enterprise, it was more in Retinopathy of Prematurity (ROP) in phone or the PC using the lossless luation that employs Analytic Hierar- “best methodology” between these likely that funds would be limited and middle-income countries like India is Automated Binary Optimization (ABO) chy Processing (AHP), a multi criteria strategies. Sensitivity analysis and the needed prioritization. In our own set- born out of the skewed compression technology decision model for comparing the analysis of uncertainty were also per- ting, we were able to convince the demand and supply (patented). Images were KIDROP strategy (which uses a single formed to evaluate the maximum and Government to fund only one Retcam problem plaguing ROP also graded by these Retcam shuttle for 6 districts) to three minimum budgetary requirements in per zone. management, the largest technicians and vali- alternate strategies of ROP screening. each strategy. ‘Best case’, ‘worst case’ cause of infant blindness dated against binocular and ‘balanced scenarios’ were com- Economic Impact worldwide. indirect ophthalmo- Alternate Strategies puted against each strategy and inter- The economic impact of the KIDROP scopy by the ROP expert. The three alternate strategies were vention to determine the best strategy programme can be indirectly f the 27 million The KIDROP pro- hypothetical and were: in these situations. measured by evaluating the blindness live births annu- gramme currently serves 1) Parents in the rural outreach are When the maximum patient cover- prevention quotient in financial O ally in India, 51 neonatal intensive educated, sensitized and urged to age was considered as the goal (‘the equivalents. Thus far 512 children about 8.8% are born care units (NICU) in travel with their infants to the city for best case scenario”) (which should be have received vision restoring laser below 2000 grams and rural and semi-urban screening at designated sites. the aim of any screening intervention treatment. The return on investment are at risk of ROP. How- regions and runs on a 2) Rural infants are to be screened in the community), the best ROP in the national perspective may be ever, a majority of these Anand Vinekar, MD, FRCS non-profit grant by the screening strategy for all three scenar- calculated as follows: Each of these infants are born in rural Institute. 18 of these ios i.e. the provider’s perspective 512 infants will survive to an average areas and remain unscreened. With centers are in a remote zone 500 kil- (funding organization), the patient’s of 65 years (average life expectancy) less than 500 retinal surgeons and 20 ometers away and are co-managed in perspective and a ‘balanced scenario’ and earn approximately USD 900 per ROP specialists, there is a huge unmet a public private partnership (PPP) was the KIDROP model. In the poorest annum (per capita income). This is a need for ROP management in India. with the State Government. In this coverage (‘worst case’), best ROP federal saving of over USD 25 million! PPP the Government has granted USD screening strategy for the funding All this for an investment of less than Asia’s First Tele-ROP 0.52 million (2009-2012) to set up two organization was the KIDROP model, USD 250,000 ! The social returns are, Screening Programme zones that cover six districts each. Our but from the patient’s perspective and of course, priceless. In 2008 we started Asia’s first contribution will include free training, for the balanced scenario it was the As we previously reported, barriers tele-ROP screening programme in image reading and treatment. The Figure 2: A PROP in a rural infant. multiple Retcam model. of cost and infrastructure must be Southern India to cover unscreened government will provide for the met. The cost of the camera alone is rural neonatal care centers in the state equipment, its maintenance and at their respective district hospitals by Best Screening Strategy currently approximately USD135,000 trained experts using indirect oph- in Four out of Six Situations in India. The greatest barriers, how- thalmoscopy one day a week who Hence, the KIDROP model ranked as ever, are the “mental barrier” of the travel from their city based practices. the ‘best screening strategy’ in four care-givers created by a mixture of 3) Screening is performed by out of six situations. In all situations poor awareness, inadequately trained trained non-physicians using Retcams tele-ROP ranked higher than the other personnel and unwillingness to adapt at each district headquarters. The last interventions where the specialist or to innovation. However, there is hope strategy is similar to KIDROP but the patient had to travel for screening. that with time, patience and passion, these barriers can be overcome.

A Viable Model In conclusion, tele-ROP is a viable model in middle-income countries. The cost utility analysis comparing the KIDROP model with other alter- nate strategies indicates that the KIDROP model, which uses a single Retcam shuttle to service a zone of roughly 300-400 kilometers radius in six districts using non-physicians (trained technicians) is the most cost- effective method of providing the

Anand Vinekar (4) standard of care in ROP screening in Figure 1: Technicians imaging as project manager uploads. centers which are rural or peripheral with limited access to health care of Karnataka. Under this KIDROP financial compensation of the tech- given the current scenario of limited (Karnataka Internet Assisted Diagnosis nicians in the outreach. experts and funds. Each country with of ROP) programme, technicians were Thus far, we have completed over similar demographic and financial trained to image, interpret, store and 25,000 imaging sessions and recruited milieu as India must explore tele-ROP upload images taken on a mobile over 6500 infants into the ROP scree- Figure 3: Infants sharing an incubator in rural NICU. as a viable financial model and cus- wide-field digital retinal camera, the ning programme in more than twelve tomize it to suit their local needs. W Retcam Shuttle (Clarity MSI, Pleasan- districts of Karnataka state covering needs to have several Retcams The lowest rank in all six situations ton, CA, USA) on to a secure server for two zones, each having a radius of servicing each district. was the strategy where mothers had to Thu, 16 February 13.00 – 14.30 hrs experts to review remotely. Together care of around 400 kilometers. In this travel to the city with their infants for Hall 7 with our technology partners we study, we present a cost-utility evalu- Criteria for Cost-Effectiveness ROP screening. This was the strategy Session: PED - Pediatric Retina developed a comprehensive software- ation of the KIDROP programme. We Cost-effectiveness in all four strate- that had the lowest cost but produced hardware platform, which allowed used the financial audited data in our gies was computed using three crite- the poorest coverage, since most ( Author: Anand Vinekar, MD, FRCS ria: parents in rural areas were daily wage Associate Professor & Head 1) Organizational costs: costs workers and belonged to the lower Department of Pediatric Retina References incurred by the ‘provider’ (who could economic strata making travel costs Narayana Nethralaya Postgraduate Institute be a private or a public enterprise or a with the family a heavy burden on of Ophthalmology Vinekar A.: IT-enabled innovation to prevent infant blindness in rural India: the KIDROP public-private partnership) their resources. Banglore, India experience. Journal of Indian Business Review; 2011; 3(2):98-102. Govindrajan, V.: A telemedicine innovation for the poor that should open eyes. Harvard 2) Burden weight: burden to the The fact that repeated visits are need- E-Mail: [email protected] Business Review 2010 November 7, available at: http://blogs.hbr.org/govindara- parents or guardians of the child ed before discharge from the screen- www.narayananethralaya.org jan/2010/11/ including direct and indirect costs ing programme, further adds to prob- www.facebook.com/KIDROP Min of External Affairs Publication, Government of India: Unique experiment in Tele-med- 3) Disease coverage: number of lem of travelling which compounds icine: Tele-ophthalmology provides a new hope in preventing infant blindness in rural ‘disease susceptible’ as a proportion the costs for the family. Poor compli- ( Acknowledgements: The KIDROP infants, India Perspectives, 2010;24;70-1. Kreatsoulas, J.: Progress in ROP management through Tele-ophthalmology. Retina Today, covered under the strategy. ance to complete the screening meant teams at Narayana Nethralaya Postgra- 2010; December. Using AHP, the overall ranks com- higher risk of blindness. The multiple duate Institute of Ophthalmology, Ban- Vinekar, A.: The ROP challenge in rural India: preliminary report of a telemedicine screen- paring these strategies were then cal- Retcam stra-tegy had the best cover- galore and in North Karnataka and The ing model. (In) International Experience with Photographic Imaging for Pediatric and culated by the matrix multiplication age but caused a larger financial bur- National Rural Health Mission (NRHM), Adult Eye Diseases. Retina Physician 2008, Supplement 9-10. of the AHP Modified Weights matrix den on the organizations that fund Min. of Health and Family Welfare, (KIDROP updates are available on www.facebook.com/KIDROP ) with that of the Priority Weights and manage the programme. In a pub- Government of Karnataka, India. 4 | woc 2012 World Ophthalmology News | 2012

Phaco Nightmares and Worst Case Scenarios A Video Based Symposium

CHENNAI – Various complications can The haptics are then fixed trans-scle- erosion, knot exposure, loosening of trating keratoplasty in aphakic bullous occur during phako surgery, but the worst rally into scleral pockets created at the knot et cetera also do not occur with keratopathy cases or with endothelial case scenarios are dropped lenses and edge of the flap with a 26 G needle this technique. keratoplasties. A dropped three piece nuclei. This course will present various (figure 3). With the help of fibrin glue The glued IOL technique has IOL does not need to be explanted. It is crazy cases and their management. the scleral flaps are then stuck down. evolved over time. Since its inception, possible to refixate the same IOL with It is ideal to use either a 23 G infusion its use has been extended for many the glued IOL technique. he usage of diamond tipped cannula (which is easy to use for ante- more indications. An aniridia IOL can The glue used is a quick-acting sur- forceps in the removal of rior segment surgeons as well) or an be implanted using this technique. We gical fibrin glue sealant derived from T dropped intraocular lenses human blood plasma (Tisseel, Baxter, (IOL) will also be shown. Difficult USA), with both hemostatic and ad- cases like subluxated lenses, posterior hesive properties. Fibrin glue is com- polar cataracts, colobomas and com- posed of two separate solutions of plications will be presented in videos. fibrinogen or Factor 1 and thrombin. For the management of the intraoper- Amar Agarwal Fibrinogen is activated by thrombin to ative floppy iris syndrome (IFIS) the form fibrin monomers. Activated implantation of the glued IOL will be haptic above the iris and the other Factor XIII polymerizes fibrin taught with endocapsular rings and haptic extending outside the incision. monomers to form a stable fibrin clot, capsule retractors. The nucleus is emulsified with the thus mimicking the last stages of the

The unsteady capsular bag has to phacoprobe above the IOL optic. Cor- Agarwal (4) clotting cascade. Aprotinin delays be handled delicately. If the surgeon is tical cleaning is done and the IOL is Figures 1 and 2: An IOL may be use as a scaffold to prevent the nucleus from dropping into fibrinolysis, the process that leads to not careful, a PC IOL could drop into then placed over the remnants of the the vitreous in case of a posterior capsular rupture. the breakdown of blood clots. The the vitreous cavity. So the ophthalmic capsule in the ciliary sulcus. This can commercially available fibrin glue surgeon should know how to handle be performed in eyes with moderate to anterior chamber (AC) maintainer that we used is virus inactivated and these situations. Repositioning an IOL soft cataracts. This technique helps to during the course of the procedure to is checked for viral antigen and anti- and refixating the bag are maneuvers avoid the extension of the corneal keep the globe well formed. The inter- bodies with polymerase chain the experienced surgeon has to know. incision and thereby limits the induced vention may be performed as an reaction; hence the chances to trans- This symposium will teach all there is astigmatism. injectable glued IOL technique using a mit an infection are very low. W to know on these subjects through three piece foldable IOL. This allows videos. The “Glued IOL” Technique faster and easier surgery with all the Fr, 17 February 10.30 – 12.00 hrs “Glued IOL” as a technique for PCIOL advantages of a smaller incision. As Hall 7 How to Use an IOL as Scaffold fixation in eyes with absent or insuf- an alternative the surgeon may use a Session: IVI - Phaco nightmares and worst The use of an IOL as scaffold is ficient capsular support was first pro- three piece non foldable IOL. Only case scenarios another trick the attendees of the ses- posed in 2007. Since then a large single piece foldable IOLs cannot be Figure 3: The “glued IOL” technique has sion will learn: A foldable IOL is used number of cases has been operated on used since something firm is needed become a rescue technique for many com- ( Author: Prof. MD Amar Agarwal, as a scaffold for preventing the nucle- with this technique with the longest to be tucked into the sclera tunnel and plicated cases. MS, FRCS, FRCOphth us fragment from descending into the follow-up being more than 3.5 years. then to be glued. Dr. Agarwal‘s Eye Hospital vitreous in cases of posterior capsular The basic technique starts with crea- The trans-scleral fixation of the IOL have extended its use as a novel bio- 19 Cathedral Road ruptures (figures 1 and 2). After ting two lamellar scleral flaps and per se makes it very stable with synthetic graft to simulate the anterior Chennai - 600 086, India removing the vitreous in the anterior retrieving the haptics of the IOL minimal pseudophacodonesis/ segment for Anterior Segment Trans- Tel: +91(0)44-2811-2811 chamber by anterior vitrectomy, a through sub-flap sclerotomies (1 mm endophthalmodonesis as compared to plantation (AST) in eyes with large Fax: +91(0)44-2811-5871 three piece foldable IOL is injected via from the limbus) using 23 G Micro- traditional suture fixated IOLs. Prob- anterior staphylomas. The procedure E-Mail: [email protected] the existing corneal incision with one Surgical Technology (MST) forceps. lems related to suture degradation, can be combined with either pene- www.dragarwal.com

Excellent Medical Knowledge ever since Old Arabian Ophthalmology

THÜNGERSHEIM – Thinking of Arabia, The earliest oculist known by name tius”, was the personal doctor of a His compendium “Al-hawi” (“Contin- na wrote about the whole medicine, many people in Europe or America think should be Iry in Egypt. He must have caliph in Baghdad. He published ens” in Latin] was published after his including ophthalmology. He carried of oil, of big, modern buildings, of camels lived between 2723 and 2563 BC. His different translations and compila- death. He was the first to describe that on research about the anatomy of the or of the desert. Only few of them will grave was found close to the pyramids tions of Greek-Alexandrian medicine pupils contract in the case of bright- eyes and the therapy of eye diseases. have Arabian medicine, especially oph- of the kings Cheops, Chephren and and the first textbook of ophthalmo- ness and dilate by darkness. These examples not only prove the thalmology in mind. But the world has to Mykerinos. The inscriptions on his logy in Arabian language “Kitab al- Abul Qasim Khalaf Ibn Abbas Al- significance of the old Arabian oph- be most grateful to Arabia for its merits in grave name him “the doctor of the aschr maqalat fi al-ain” (Book of the Zahrawi (910?–1013[!]?), in Europe thalmology, but also of the Arabian medicine. For hundreds of years the pharaoh, guardian of the royal intes- Ten Treatisies of the Eye). The Arabian known as “Abulkasim”, published his medicine in general and of all the medieval Europe benefited from Arabian tines-exit and oculist of the palace”. original script has been lost, but we work about surgery, “Al-tasrif”, other sciences. Why did this great medical knowledge and from Europe this So here we find a very early speciali- know from Latin translations of 11 around the year 1000. It may be one of knowledge have to be imported into knowledge spread all over the world. sation in medicine and just in oph- chapters: the earliest Arabian works about Europe? One reason may be the fact thalmology, because Iry was men- 1. Nature of the eye surgery and contains more than 200 that many Arabs could read and write eographically Arabia can be tioned as an oculist! 2. Nature of the brain illustrations about surgical, amongst at the time – unlike the majority of defined as the area of About 2000 BC we find a statement 3. Nervus optici and the view them ophthalmological, instruments. people in Europe. Literacy was encou- G northern Africa and the in the book of laws of Hammurabi 4. Hygiene For the treatment of an entropium he raged by Mohammed, who demanded, Arabian Peninsula. But in the Middle about the therapy of eye-diseases in 5. Causes of eye diseases suggested cauterisation and burning. that all the faithful have to improve Ages the Arab world spread much Babylonia and Assyria. The medical 6. Marks of eye-diseases The developing scar should cause a their knowledge: “Search for knowl- further. The scientific medical works rules start with penalties for ophthal- 7. Effects of medicaments general correct position of the eyelid. edge from the cradle to the grave. of the 8th up to the 13th century, mological mistakes by oculists. This is 8. Eye-medicaments Abu Ali Al-Husaini Ibn Abdallah Who is searching, prays to God!” W published in Arabian language, a proof for the high standard of oph- 9. Therapy of eye-diseases Ibn Sina (980–1037), “Avicenna”, was covered an area from Spain in the thalmology in this area and these 10. Recipes born in the area of Buchara/Tajikistan. Fr, 17 February 10.30 – 12.00 hrs west as far as Afghanistan in the east, times. The 20 m long “Papyrus Ebers” In some Latin prints an 11th chap- Like Razes he studied law, mathe- Capital Suite 7 and from the Caucasus in the north was written about 1550 BC and ter is added about ophthalmic surgery. matics, astronomy and philosophy Session: HIS - History of Ophthalmology 1 down to Central Africa in the south. includes therapeutic suggestions for Abu Bekr Muhammad Ibn Zakari- and then medicine. His work “Al- about 30 eye-diseases. yya Al-Razi (850–923/932), in Europe qanum fi altibb” (Guideline for the ( Author: Frank Krogmann Milestones in History called “Razes”, was born in Raj/Persia. medical practise), also known as Kirchgasse 6 The Arabian medicine was strongly Famous Names in He studied Philosophy, Astronomy „Canon medicinae“ was a true guide- 97291 Thüngersheim, Germany influenced by the Greeks, but as well Arabian Ophthalmology and Chemistry. He started his medical line. For 500 years this book was the Tel: +49(0)9364-811543 by Egypt, Byzantium, Mesopotamia, Abu Zaid Hunain Ibn Ishaq Al-Ibadi career at the age of 30 and became leading book for medicine in Europe, Fax: +49(0)9364-811559 Persia and India. (808–873), in Europe called “Johanni- one of the important Arabian doctors. beside the scripts of Galenos. Avicen- E-Mail: [email protected] World Ophthalmology News | 2012 woc 2012 | 5

Searching for the Best Treatment Strategy Is there still a Role for the Laser in the Treatment of Macular Edema?

LIMA - Diabetic macular edema is a thickness remained unchanged. About ranibizumab with differed laser. After strategy to deal with macular edema Sat, 18 February 10.30 – 12.00 hrs leading cause of blindness among 20% showed the worst visual acuity at one year follow-up in both groups the in order to maintain and to improve Hall 3 working people in the world. Laser treat- the beginning of the study. visual acuity improved compared to visual outcomes in diabetic patients: Session: RET - Macular edema ment was the only effective treatment Anti-VEGF drugs (ranibizumab and patients treated with laser alone. The anti-VEGF injections followed by that we had two decades ago to prevent bevacizumab) have demonstrated difference between combined treat- focal/grid laser photocoagulation, ( Author: Dr. José A. Roca further loss of vision due to macular their effectiveness in reducing retinal ment (ranibizumab plus laser) versus triamcinolone injection followed by Clinica Ricardo Palma edema. Now we have intravitreal injec- central thickness and improving laser treatment alone after one year focal/grid photocoagu-lation, or Av. Javier Prado Este 1066 tions and some oral drugs that could help visual acuity in patients with macular amounted to nine letters. The results photocoagulation alone. San Isidro us dealing with this important cause of edema secondary to diabetes. Investi- after two and three years of follow-up But the laser is, in these days, one Lima 27, Perú blindness. gators from the DRCRnet group con- are necessary to estimate the real of the most important tools that oph- Tel: +511(0)224-2224 ducted a study comparing ranibizu- benefit of combined treatment. We thalmologist have to control macular +511(0)224-2226 e know that triamcinolone mab with previous laser versus still need to keep looking for the best edema. W E-Mail: [email protected] and anti-VEGF injections W can effectively reduce macular thickness, and in some cases help to improve vision. But to have to inject an eye several times to achieve a steady result is neither desirable to the patient nor to the physician. That is why other forms of treatment with or without laser photocoagulation are currently under investigation. Roca José A. Roca

The Early Treatment Diabetic Retinopathy Study group (ETDRS) demonstrates that focal/grid laser photocoagulation reduced the risk of moderate loss of vision in patients with clinically significant macular edema (CSME) by 50% (from 24% to 12%) during the period of three years. On the other hand an improvement of the visual acuity (VA) was observed in less than 3% of cases, based on a gain of 15 letters after three years, 17% of the patients showed any improvement in vision. The characteristics of the participants in the ETDRS could limit the benefit obtained, because an important proportion of patients enrolled in the ETDRS had a basal VA of at least 20/40, so it was very diffi- cult to reach an improvement of three lines. Among those participants that could improve three lines or more, 40% obtained it. The Diabetic Retinopathy Clinical Research network (DRCRnet) com- pared intravitreal triamcinolone with the focal/grid laser treatment. Three years after the start of studies the group that had been treated with the laser had a mean improvement of five letters versus zero letters in the triam- cinolone group. More patients in the triamcinolone group suffered from cataract and ocular hypertension than in the laser group. In about 50% of the patients treated with laser the retinal central 6 | woc 2012 World Ophthalmology News | 2012

A Giant Stride in Optimizing the Refractive Outcome Combining Multifocal and Toric IOLs

AHMEDABAD – Many patients have a sig- practice. The ideal solution would calculation formula, is more impor- astigmatism as unilateral. The magni- 90% of the eyes. In a questionnaire nificant unilateral or bilateral astigma- have been to combine the concept of tant now than ever before. tude of astigmatism was in the range designed to find out if they could per- tism. To provide an optimal refractive out- multifocality and toricity in a single The next step towards a successful of 1 to 1.25D in 50% of the eyes. A form various routine activities at dis- come after cataract surgery IOL. The new Multifocal outcome would be to ensure an opti- significantly large number of patients, tance, intermediate and near, we multifocal IOLs alone are Toric IOL has answered mal surgical result by using appro- who opted for this IOL, had a mode- found that all the 50 patients reported not enough. the need of the hour and priate ophthalmic viscosurgical devic- rate to high myopia. This gave us an spectacle independence in their every- promises to provide a es (OVDs) and an appropriate surgical insight into the preference pattern of day life, following ReSTOR Toric IOL ultifocal IOLs customized refractive technique. Appropriate size and cen- our patients. It would seem that the implantation. have steadily outcome by integrating tricity of the anterior capsulorhexis myopes, who are blessed with good M gained popu- the management of cor- has become a requirement, in order to unaided near vision, are motivated to Attention to Detail larity among patients neal astigmatism during provide an adequate capsular ‘wrap’ retain that ability even after cataract At this juncture, it would be fair to say since they provide a cataract surgery itself. all around the optic, which would help surgery. The postoperative visual per- that the ReSTOR Toric IOL offers a greater degree of spec- While the Multifocal to maintain the effective lens position formance, assessed at 1 month, was promising opportunity to optimize the tacle independence for Toric IOL offers to be a (ELP). Finally the precise placement of definitely encouraging. Unaided refractive outcome in those patients activities at different dis- safe and effective option who have cataract with signifi-

tances following cataract (3) Vasavada for those of our patients cant corneal astigmatism. surgery. However as has Abhay Vasavada who are motivated to Incorporating this IOL into our been reported, presence reach a greater degree of practice would practically need of astigmatism of 1D or more would freedom from spectacles but have a no additional learning curve if significantly degrade the visual per- significant astigmatism, the success of one is familiar with multifocal formance of a multifocal IOL. To this IOL hugely depends on the plat- and toric IOL implantation. manage the co-existent astigmatism, form that we provide for it. Hence, Successful performance of this an additional intervention like LASIK raising the bar of precision at every multifocal toric IOL largely or limbal relaxing incisions (LRI) step of cataract management cannot hinges on our attention to would be required. But each procedure be emphasized enough. detail and a diligent effort to has its own limitation that is likely to ensure as much precision as is make the outcome less predictable and Understanding Astigmatism Figure 1: Intraoperative toric axis alignment of Figure 2: ReSTOR Toric IOL - 1 month postoper- possible, at every step of cata- satisfactory. In a survey of our own The due diligence at our end begins ReSTOR Toric IOL. ative. ract management. W practice we found a high prevalence with the fundamental understanding of significant corneal astigmatism of astigmatism and all its relevant the toricity of the IOL on the intended distance visual acuity was found to be Fr, 17 February 10.30 – 12.00 hrs (> 1D) similar to what has been re- components, like estimation of its axis, is of paramount importance 20/30 or more in 85% of the eyes. Hall 10 ported in literature. We found that magnitude and axis, choosing the (figure 1). Unaided near visual acuity of N/8 or Session: CAT - Astigmatism management at nearly 40% of our patients with cata- appropriate type (regular astigmatism) Our experience of Multifocal Toric more, was seen in all the eyes with a the time of cataract surgery ract also had significant unilateral or and knowing our own surgically IOL implantation has been with the fairly good reading range of 25 to bilateral corneal astigmatism and induced astigmatism. Since we are ReSTOR Toric IOL (Alcon Laboratories, 40cms. Residual refractive astigma- ( Authors: Abhay Vasavada MD, FRCS hence it was not possible to provide now aiming at a consistently predict- Fort Worth, Texas). This single piece tism was found to be 1D or less in all (England), Lajja Shastri MD an optimal refractive outcome with able refractive outcome, our need for hydrophobic acrylic IOL has an the eyes. Recently, Visser et al (JCRS, Iladevi Cataract & IOL Research Centre multifocal IOL implantation alone. precision demands employing instru- aspheric apodized diffractive configu- November 2011) have reported the Raghudeep Eye Clinic, mentation that yields accurate esti- ration on its anterior surface and visual outcomes following AT Lisa Gurukul Road, Memnagar, Customized Refractive Outcome mation of the corneal astigmatism as toricity on its posterior surface. Of the Toric IOL (n= 45 eyes), which is a plate Ahmedabad - 380 052 India In other words, significant corneal well as a precise biometry evaluation. 61 eyes (50 patients) that have received haptic multifocal toric IOL. They have Tel: +91(0)79-27492303, 27490909 astigmatism was perhaps the most Ensuring negligible spherical equi- the ReSTOR Toric IOL in our practice, reported residual refractive astigma- Fax: +91(0)79-27411200 common hurdle to multifocal IOL valent, by using appropriate IOL nearly as many patients had bilateral tism of 1D or less in approximately E-Mail: [email protected]

Better Arabian Night Classification The Cultural Event at the Emirates Palace Publisher: Dr. Hans Biermann (bie) HOUSTON - Tumours of the lacrimal gland Biermann Publishing Group are rare but an important cause of ocular Otto-Hahn-Str. 7 morbidity and cancer-related mortality. D-50997 Köln Germany Tel: +49(0) 22 36-376 - 0 n this section the multi-discipli- Fax: - 999 nary management of epithelial Internet: www.biermann.net I tumours of the lacrimal gland will Editor-in-Chief: be discussed with a view to better Dieter Kaulard (dk) classification of tumours based on size Tel: +49(0)2236-376-408 and AJCC criteria. In addition, Fax: +49(0)2236-376-409 E-Mail: [email protected] tumours of the lacrimal drainage apparatus and their multi-disciplinary Editorial Team: management using globe preserving Jeanette Prautzsch (jp) surgery followed by radiation therapy Britta Achenbach (ac) will be discussed through illustrative Managing Editor: case presentations. W Michaela Schmid The venue for the cultural night: Graphic Artist: Fr, 17 February 8.30 – 10.00 hrs The Abu Dhabi Emirates Palace. H. Udo Pößneck

Conference Room A/B Kempinski Session: ONC – Orbital Tumors Marketing: ABU DHABI [jp] - The venue for the cul- Thijs van Egeraat of private beach the hotel is surround- ski Group. The cost to build the hotel Tel: +49(0) 22 36-376 - 526 ( Author: Bita Esmaeli, MD, FACS tural night on 17 February reminds of the ed by 85 hectares of beautiful gardens. that opened in November 2005 were E-Mail: [email protected] Professor of Ophthalmology stories of the Arabian nights: The Abu It has its own luxury shopping mall, a 11.02 billion AED (United Arab Emir- The University of Texas Dhabi Emirates Palace, the biggest and marina and a helipad. 2000 employes ates dirham, 1 AED = 0,2722 USD). M. D. Anderson Cancer Center most luxurious hotel in the world. from 50 countries work at the The 114 domes are decorated with 1515 Holcombe Blvd, Unit 1445 Emirates Palace. gold leaf. Many of the suites are fur- Houston, Texas 77030, USA arble, gold and precious The building was designed by the nished in gold and marble. The six Tel: +1(0)713-792-4457 wood species remind of the renowned architect John Elliot RIBA. Rulers’ Suites in the topmost floor are Fax: +1(0)713-794-4662 big buildings of the golden It is owned by the Abu Dhabi govern- reserved for Emirati royalty and M W E-Mail: [email protected] age of the Orient. Located on 1.3 km ment and is managed by the Kempin- dignitaries. World Ophthalmology News | 2012 woc 2012 | 7

The End Game for Blinding Trachoma Where do we Stand as far as Global Elimination of Trachoma is Concerned, and how are we Going to Close the Gap?

GEORGIA – Blinding trachoma, one of the levels of recurrence after trichiasis oldest known infectious eye diseases, surgery. Reasons for this are poor may be facing its end game. technique and quality of surgery. With a major backlog of TT surgeries he world’s leading cause of even after prevention and treatment preventable blindness, tracho- targets have been met, ophthalmolo- T ma, brings extraordinary gists could play a critical role in this human suffering and economic devas- area by providing training and super- tation to tens of millions of people, vision for those performing TT sur- mostly women and children in poorer geries. countries. Yet as a result of develop- ment and targeted interventions it is SAFE Strategy now limited to an estimated 59 coun- Our goal to eliminate blinding tra- tries, often affecting the poorest popu- choma in less than nine years is, lations. indeed, ambitious, but it is also achievable. The primary reason for New Global Strategic Plan hope is the World Health Organization A new global strategic plan — 2020 (WHO)-endorsed SAFE strategy. SAFE INSight — created by an international brings Surgery, Antibiotics, Facial coalition of partners, lays out specific cleanliness and Environmental actions to take and milestones to meet improvement to the poorest commu- that could lead to elimination of nities where trachoma is most likely to blinding trachoma by the year 2020. be found. To implement SAFE, na- At this year’s World Ophthalmology tional governments and non-govern- Figure 4: Four elements constitute the SAFE strategy.

improved access to water and sani- it cost to achieve that elimination tation, are the most crucial elements goal? in the fight to stem transmission. Tra- 2020 INSight calculates that an choma control programs must be estimated $748 million in funding is underway by 2015 in affected coun- needed to fully implement the SAFE tries to be sure that there is enough strategy to prevent and treat blinding time to eliminate the disease by 2020. trachoma. Eliminating the disease in 2020 INSight lays out five guiding Africa alone would boost the conti- principles that provide a framework nent’s GDP 20-30 percentage points for making progress on the path to based on conservative annual produc- elimination: urgency for action and tivity loss estimates. A dollar spent on scale-up; accountable ownership by trachoma control is not only well countries so they can integrate actions spent but yields personal and eco- into the national health services; inte- nomic benefits to individuals, com- Figure 1: 320 million people live in areas Figure 2: More than 8 million people suffer from trachomatous trichiasis and require surgi- gration so that trachoma focused munities, and countries. As 2020 where they can be exposed to trachoma. cal lid rotation to prevent them from going blind. efforts are aligned with activities for INSight states, “The total cost is rela- tively small, the potential for impact Congress in Abu Dhabi, there is no enormous.” better time to focus on what is needed to reach this ambitious goal: country One of Five Priority Diseases leadership, international coordination, for VISION 2020 logistical and planning support, and Those of us involved in the fight adequate funding. Ophthalmologists against trachoma are hopeful. Tra- around the world have a role to play. choma was named as one of five priority diseases for the VISION 2020 8 Million People Suffer from “The Right to Sight” global initiative Trachomatous Trichiasis for the elimination of avoidable blind- An estimated 320 million people live ness launched by WHO and the Inter- in areas where they can be exposed to national Agency for the Prevention of trachoma, a Neglected Tropical Blindness back in 1999. There has

Disease (NTD). Repeated infections All photos courtesy of ITI been much great news to report over with Chlamydia trachomatis of the Figure 3: Facial cleanliness is one of the Figure 5: A dollar spent on trachoma control is not only well spent but yields personal and the past 12 years. If the global com- conjuctivae and scarring lead to main aspects of the SAFE strategy. economic benefits to individuals, communities, and countries. munity uses our new strategic plan to inturned eyelashes, entropion causing focus time, attention and funding, tra- trichiasis. This extremely painful con- mental organizations around the endemic for trachoma and require other NTDs, eye care and development choma doesn’t stand a chance. dition ultimately leads to corneal world are uniting like never before. implementation of the SAFE strategy. strategies; efficient, coordinated part- We hope that those of you gathered opacity and blindness. Over the last year, the International The total population in these areas is nerships with all stakeholders; and for this year’s World Ophthalmology Trachoma blinds one person every Trachoma Initiative worked with fellow 110 million, and another 210 million tailored interventions to meet local Congress in Abu Dhabi will join us in 15 minutes and makes one person partners in the International Coalition live in districts where trachoma is sus- needs and context. this fight to end blinding trachoma. experience severe sight loss every four of Trachoma Control (ICTC) to create pected but no data are available to We invite you to contact us to learn minutes. Over 8 million people are the global strategic plan 2020 INSight. guide public health interventions and Benefits at the Human and more about the need for training and suffering from trachomatous trichiasis The plan takes a hard look at where where surveys are urgently needed. Economic Level supervision for TT surgeries and about (TT) the final, painful stage of this eye we are now, where we want to go over Delayed action will be costly. There is the part you can play. W disease and require surgical lid rota- the next nine years, how we get there, Immediate Action Needed the human cost that occurs when tion to prevent them from going blind. and the cost and impact of finally in 14 Countries vision loss or worse, blindness, leads Fr, 17 February 10.30 – 12.00 hrs However, studies have shown high eliminating blinding trachoma. The good news is that nine countries to loss of social status, stigmatization Conference Room B/C Mapping and assessing the mag- with trachoma have already reported and reclusion from society. There is Session: WFS - Can trachoma be eliminated in nitude of the disease is critical to de- achieving elimination targets. More the economic burden of trachoma on the next decade: what are the challenges? References: fining areas that are priority for than 80 percent of the burden of the lives of individuals, families, and implementation of trachoma control active trachoma is now concentrated communities that is enormous. Even ( Author: Dr. Danny Haddad 1. 20220 INSight can be found at http:// efforts. About 1,115 districts in in 14 countries, where immediate conservative estimates suggest an Director www.trachomacoalition.org/node/713 2. Rajak SN, Makalo P, Sillah A et al. Tri- endemic countries have been surveyed action is needed. Scaling up public annual loss of productivity due to tra- International Trachoma Initiative chiasis surgery in the Gambia: a in the last 12 years, but data must be health interventions described in the choma between $3 billion and $6 bil- 325 Swanton Way 4-year prospective study. Invest Oph- gathered in at least 1,293 more dis- SAFE strategy, including antibiotic lion. Eliminating blinding trachoma Decatur, Georgia 30030, USA thalmol Vis Sci 2010;510:4496–5001. tricts to complete the picture. Out of treatment with Zithromax®, which is will clearly bring benefits at the E-Mail: [email protected] the surveyed districts, 559 are generously donated by Pfizer Inc, and human and economic level. What will www.trachoma.org 8 | woc 2012 World Ophthalmology News | 2012

Water-Drinking Test Rapidly Evolving Field Revival of an Abandoned Diagnostic Tool New Therapies for Wet AMD

SÃO PAULO – The water- a mean of 10.26 times in KARLSRUHE – The treatment of wet age- ability to induce endothelial cell Thus, antagonization of those mole- drinking test is helpful to the literature18 and has related macular degeneration (AMD) is apoptosis. cules should exert an antiangiogenic assess the IOP profile of glau- been the title of three edi- the most rapidly evolving field in ophthal- effect. comatous patients. torials in peer-review mology. Laser treatment was replaced by 2. VEGF and Sphingosine-1-phosphate (S1P) is a journals18-20. photodynamic therapy (PDT) which was VEGF-Receptor bioactive lipid molecule that stimu- he water-drinking It has been used to assess able to reduce the vision loss signifi- Once VEGF is generated therapeutic lates endothelial cell migration, pro- test was first the quality of treatment, cantly. Today we are already able to agents which directly target the VEGF liferation, and survival in vitro, and T described by Schmidt and how a given eye is able increase vision in wet AMD-patients molecule (ranibi- tumor angiogenesis in as a diagnostic tool for to control its IOP. Also, the either by using ranibizumab/bevaci- zumab/bevacizumab vivo. Again, targeting 1 glaucoma . However, it was Susanna IOP peaks of the water zumab or VEGF-Trap. or VEGF-Trap) are this molecule should later abandoned due to its Remo Susanna Jr. drinking-test strongly cor- used. This is the reduce proliferative poor diagnostic accuracy2,3. relate and are in agreement n addition, there are numerous most advanced activity. with IOP peaks that normally occur treatments under investigation. approach. POT-4 (Potentia Growing Interest during the day. I Those approaches can be More anti-VEGF Pharmaceuticals, Inc.), a Recently this test was revived with a This lecture will show the impor- grouped according to the therapeu- molecules such as small molecule deriva- new purpose. Studies have shown that tance of this test to assess the IOP tic target: KH902 are currently tive of Compstatin is the water-drinking test may be used profile of glaucomatous patients and under investigation. directed against com- as a surrogate for detecting patients how it can be used to make thera- 1. VEGF KH902 is a fully plement factor C3. who have IOP spikes not identified peutic decisions. W Cascade human fusion POT-4 is a cyclic 13 during office hours.4,5 The water- Multiple molecular interactions final- protein containing amino acid peptide,

drinking test has also been used to Thu, 16 February 13.00 – 14.30 hrs ly result in the production of vascular key domains from Augustin which interferes with evaluate the effect of treatment on Hall 11 endothelial growth factor (VEGF). A vascular endothelial Albert J. Augustin the cleavage of C3, the reducing IOP peak and fluctuation, Session: GLA - Intermediate key step in the VEGF production growth factor re- component all 3 path- both with ocular hypotensive medi- involves a molecule known as mTOR ceptors 1 and 2 with human immuno- ways of complement activation con- cations and filtering surgery6-13. Also, ( Author: Remo Susanna Jr. MD (mammalian Target of Rapamycin), a globulin Fc. verge on. It is the first complement the peak of the water-drinking test Professor and head protein kinase that regulates cell pro- Furthermore, there are several inhibitor studied in patients with correlates with the severity of glau- Department of Ophthalmology liferation, motility, survival and pro- approaches under investigation to AMD. POT-4 has completed phase 1 coma14 and a patients’ response to the University of São Paulo tein synthesis. It leads to the activa- target the VEGF-receptor directly and/ testing in patients with wet AMD with water-drinking test may be predictive Av. São Gualter, 99 tion of certain transcription factors, or integrins in general. an excellent safety profile. A unique of visual field progression15-17. 05455-000 São Paulo SP - Brazil including hypoxia-inducible factor 1α feature of POT-4 is that it persists as a There has been a growing interest Tel: +55(0)11-3022-2738 (HIF1α), which activates several 3. VEGF long-lasting gel deposit after intravit- in the water-drinking test among oph- Fax: +55(0)11-3022-4300 genes, including those that produce Effects real injection. The study demonstrated thalmologists. This test has been cited E-Mail: [email protected] VEGF. Following production VEGF binds to that significant levels of drug are RTP801 (REDD1) is a gene that dis- its receptors. By doing so the molecule maintained in the vitreous cavity for plays strong hypoxia-dependent initiates a series of events which are up to 6 months following a single upregulation in ischemic cells of neu- mediated by tyrosine kinase (tk). Thus, injection. A phase 2 study is currently References ronal origin. It promotes VEGF pro- tk-inhibitors should be also efficient under way. duction through the mTOR/HIF1α in counteraction VEGF-initiated Genentech/Roche is working on 1. Schmidt K. Untersuchungen über Kapillarendothelstörungen bei Glaukoma simplex. pathway. RTP801i-14 (Quark/Pfizer), effects in the tissue. anti-factor D (FCFD4514S) that in- Arch Augenheilkd 1928;98:569-581. 2. Roth JA. Inadequate diagnostic value of the water-drinking test. Brit J Ophthalmol now known as PF-4523665, is a small Currently the kinase inhibitors hibits the C3 and C5 alternative 1974;58:(1)55-61. interfering RNA (siRNA) that has been pazopanib and AL39324 are under pathway convertases. Phase 1 studies 3. Rasmussen KE, Jorgensen HA. Diagnostic value of the water drinking test in early detec- developed to inhibit REDD1 and sup- investigation. So far the following have been successfully completed. tion of simple glaucoma. Acta Ophthalmol 1967;54(2):160-164. press VEGF production as well as clinical data is being generated for Furthermore, two C5 inhibitors are 4. Miller D. The relationship between diurnal tension variation and the water-drinking test. inhibit angiogenesis. pazopanib in ophthalmology: A 28 being studied: Eculizumab/Sollris AJO 1964;58:243-247. 5. Susanna R, Medeiros FA, Vessani RM. Correlation between intraocular pressure peaks in The signaling pathways are day phase II study to evaluate the (Alexion) and ARC1905, an anti-C5 the diurnal tension curve and in the water-drinking test [ARVO Abstract]. Invest Oph- addressed by mTOR-inhibiton (Siroli- pharmacodynamic effect of pazopanib aptamer (Ophthotech). thalmol Vis Sci 2001;42:S558. Abstract nr.2995. mus (Rapamycin); Everolimus eye drops on the central retinal In summary, the inflammatory cas- 6. Susanna R Jr, Medeiros FA, Vessani RM et al. Intraocular pressure fluctuations in (RAD001); Palomid 529). thickness of AMD patients has been cade plays a significant role in this response to the water-drinking provocative test in patients using latanoprost versus Sirolimus (Rapamycin) exhibits performed. Currently, a phase IIb disease entity. Therefore, targeting unoprostone. J Ocul Pharmacol Ther 2004;20(5):401-410. 7. Christiansen GA et al. Mechanism of ocular hypotensive action of bimatoprost (Lumigan) in significant antitumor/antiangiogenic dose-ranging study is underway to this part of the pathway could be a patients with ocular hypertension or glaucoma. Ophthalmology 2004;111(9):1658-1662. activity that is coupled with a decrease investigate the efficacy of pazopanib very effective approach in the future 8. Susanna R Jr, Sheu WP; Latin American Glaucoma Society. Comparison of latanoprost in vascular endothelial growth factor eye drops in patients who are being of wet AMD treatments. with fixed-combination dorzolamide and timolol in adult patients with elevated (VEGF) production and a reduction in treated with ranibizumab injections. intraocular pressure: an eight-week, randomized, open-label, parallel-group, multicenter the response of vascular endothelial Additionally, a 12 week, open-label 5. Vitreoretinal study in Latin America. Clin Ther 2004;26(5):755-768 9. Facio AC, Reis AS, Vidal KS et al. A comparison of bimatoprost 0.03% versus the fixed- cells to stimulation by VEGF. phase II study to investigate the safety Traction combination of latanoprost 0.005% and timolol 0.5% in adult patients with elevated Everolimus (RAD-001) is the and efficacy of a single dose regimen This part of the disease entity has been intraocular pressure: an eight-week, randomized, open-label trial. J Ocul Pharmacol 40-O-(2-hydroxyethyl) derivate of of pazopanib eye drops for neovascu- underestimated so far. The elimination Ther 2009;25(5):447-451. Sirolimus and works similarly to lar age-related macular degeneration of vitreoretinal traction by means of 10. Hatanaka M et al. Additive intraocular pressure reduction effect of fixed combination sirolimus as an mTOR (mammalian is being carried out. surgery or with a vitreolytic agent of maleate timolol 0.5%/dorzolamide 2% (Cosopt) on monotherapy with latanoprost (Xalatan) in patients with elevated intraocular pressure: a prospective, 4-week, open- target of rapamycin) inhibitor. It is therefore can be reasonable when label, randomized, controlled clinical trial. J Glaucoma 2010;19(5):331-335. currently used as an immunosupres- 4. Additional Pathways traction contributes significantly to 11. Hatanaka M, Grigera DE, Barbosa WL et al. An eight-week, multicentric, randomized, sant to prevent rejection of organ in the Angiogenic Cascade the disease process. In those subjects interventional, open-label, phase 4, parallel comparison of the efficacy and tolerability transplants and treatment of renal cell Besides the VEGF-cascade tubulin- who are not responding adequately to of the fixed combination of timolol maleate 0.5%/brimonidine tartrate 0.2% versus cancer. Much research has also been inhibition (Combretastatin, fosbretab- anti-VEGF the vitreous body should fixed combination of timolol maleate 0.5%/dorzolamide 2% in patients with elevated intraocular pressure. J Glaucoma 2008;17(8):674-679. conducted on Everolimus and other ulin, OX-10X), acting against sphin- be investigated in detail. A prospec- 12. Medeiros FA et al. Intraocular pressure fluctuations in medical versus surgically treated mTOR inhibitors for use in different gosine-1-phosphate (S1P) with tive trial to investigate this approach glaucomatous patients. J Ocul Pharmacol Ther 2002;18(6):489-498. cancers. potential antiangiogenic and antineo- is pending. W 13. Chen CH, Lu DW, et al. The application of water drinking test on the evaluation of Palomid 529 (P529) is a novel plastic activities (sonepcizumab), inhi- trabeculectomy patency. J Ocul Pharmacol Ther 2000;16(1):37-42. potent antitumour PI3K/Akt/mTOR bition of pigment epithelium derived Fr 17 February 13.30 – 15.00 hrs 14. Susanna R Jr, et al. Correlation of asymmetric glaucomatous visual field damage and water-drinking test response. Invest Ophthalmol Vis Sci 2006;47(2):641-644. inhibitor. Palomid 529 (P529) inhibits factor (Ad-PEDF) or Platelet-derived Capital Suite 13 15. Yoshikawa K, Inohue T, Inohue Y. Normal tension glaucoma: The value of predictive the TORC1 and TORC2 complexes and growth factor (PDGF; E1030) and Session: PHA - Drugs for posterior segment tests. Acta Ophthalmol 1993;71(4):463-470. shows both, inhibition of Akt sig- complement inhibition (POT-4 (AL- disease 16. Armaly MF, Krueger DE, Maunder L et al. Biostatistical analysis of the Collaborative naling and mTOR signaling similarly 78898A) are further promising thera- Glaucoma Study. I. Summary report of the risk factors for glaucomatous visual-field in tumor and vasculature. peutic attempts. ( Author: Prof. Dr. Albert J. Augustin defects. Arch Ophthalmol 1980;98(12):2163-2171 17. Susanna R Jr et al. The relation between intraocular pressure peak in the water drinking Palomid 529 (P529) inhibits tumor Microtubules, a major type of Städtische Klinikum Karlsruhe test and visual field progression in glaucoma. Br J Ophthalmol 2005;89(10):1298-1301 growth, angiogenesis, and vascular cytoskeletal filament in cells, are Moltkestr. 90 18. Fan JC et al. Publication and citation in ophthalmology: glaucoma and the water provocation permeability. It has been shown that formed from tubulin subunits, includ- 76133 Karlsruhe test – wring out the old and ring in the new? Clin Exp Ophthalmol 2008;36(4):304-305. Palomid 529 (P529) inhibited both, ing α-tubulin and β-tubulin. They Germany 19. Danesh-Meyer HV. The water-drinking test: the elegance of simplicity. Clin Exp Oph- VEGF-driven (IC50 = 20 nM) and play an important role in cellular Tel: +49(0)721-974-2010 thalmol 2008;36(4):301-303. 20. Goldberg I, Clement CI. The water drinking test. AJO 2010;150(4):447-449. bFGF-driven (IC50 = 30 nM) endothe- functions, such as replication, cell Fax: +49(0)721-974-2009 lial cell proliferation and retained the movement and organelle transport. E-Mail: [email protected] World Ophthalmology News | 2012 woc 2012 | 9

A Promising Innovation for Complicated Cases Experience with the VICTUS Femtosecond Laser Cataract Surgery Procedure

HEIDELBERG – Early expe- micro Newtons (mN) in the techniques. Measured outcomes Germany was a 66 year old female nuclear cataracts (OU) and amblyopia rience with a new femtosec- manual capsulotomy group. included safety, efficacy, precision patient with a black cataract (OS) and (OS). With the first eye (OS), the pro- ond laser platform prove to be This difference was statisti- and centration of the capsulotomy, PEX, in May 2011. The surgery was cedure was performed under general promising and safe for the use cally significant. Stretching use of different lens fragmentation uneventful. Pre-operatively, the anaesthetic, whilst the procedure was in patients with pre-existing ratio measurements were patterns and ease of use of this new patient could only see hand performed under topical anaesthesia conditions such as black/ also calculated, where the femtosecond laser procedure. movements, had UDVA of 0.02 and with the fellow eye (OD). A cross brown cataracts or pseudoex- stretching ratio is defined as To date, 9 eyes (8 patients) have CDVA of -5.0/0/0 = 0.05. At 3 weeks pattern/radial cuts were applied for foliation syndrome. the circumference of the undergone the femtosecond laser ca- post-operatively, the patients visual lens fragmentation. The bilateral donut-shaped anterior taract procedure. The procedure has acuity had improved to an UDVA (OS) implantation of posterior chamber

he new VICTUS fem- Auffarth (3) capsula immediately before been safely performed in all cases, of 0.8 and CDVA of 0/-0.75/180 = 1.0. toric IOLs occurred without complica- tosecond laser plat- Gerd U. Auffarth rupture divided by the providing good visual outcomes. Lens fragmentation has been tions. The patients visual acuity Tform (Bausch + Lomb/ unstretched diameter - i.e. Docking of the curved interface is performed on all cataract grades. Dif- improved from pre-operative CDVA Technolas Perfect Vision) is a versatile 5 mm. Results found a higher stretch- straightforward and the graphic user ferent lens fragmentation patterns OD +1.25/-1.25/177 = 0.5 and CDVA system which provides refractive, the- ing ratio using the femtosecond laser interface (Figure) incorporating the such as radial cuts, ring cuts or com- 0S of +4.75 = 0.25 to postoperative rapeutic and cataract applications. The procedure of 1.67±0.08, compared to OCT allows easy procedural planning binations of both have been applied. UDVA OD of 0.8 and UDVA OS 0.32. laser features real-time OCT and also 1.36±0.05 using the manual technique. as well as monitoring. The anterior In our first case where both the In summary, early experience using employs a curved patient interface, In the clinical setting, a prelimi- capsulotomies created have been well anterior capsulotomy and the lens the femtosecond laser cataract surgery which is used in combination with the nary evaluation of the femtosecond centred and accurate. fragmentation were carried out with technique indicates it is a very pro- intelligent pressure sensors to mini- laser cataract surgery procedure on The first patient to undergo a fem- femtosecond cataract surgery, a 65 mising procedure which can be safely mise corneal applanation and corneal the VICTUS platform at Heidelberg tosecond laser anterior capsulotomy in year old male presented with cortico- and effectively used in patients with folds. CE Mark approval for the femto- University assessed the safety and pre-existing conditions. Further eva- second laser platform was recently efficacy of performing the anterior luations are on-going to obtain obtained in early December 2011. capsulotomy and lens fragmentation further data on visual outcomes, use Initially laboratory studies on pig in cataract patients with pre-existing of different lens fragmentation and human cadaver eyes were con- conditions. Patients with pre-existing patterns and the incorporation of this ducted at the University of Heidelberg. conditions such as black/brown ca- technique into routine practice. W These studies measured the maximum taracts, pseudoexfoliation syndrome applicable stretch force of the capsular (PEX), amblyopia or zonular atrophy Sat, 18 February 13.30 – 15.00 hrs bag, following anterior capsulotomy were selected to undergo the femto- Hall 10 with either the femto-second laser or second laser cataract surgery pro- Session: ISREF - Emerging Techniques in with the manual technique in freshly cedure in this single surgeon, single Refractive Surgery enucleated eyes. Results for the cap- centre evaluation. Following anterior sular bag stretch force required to rup- capsulotomy and lens fragmentation ( Author: Prof. Dr. Gerd U. Auffarth ture it found that 113±12 micro New- using the VICTUS femtosecond laser Dept. of Ophthalmology, Univ. of Heidelberg tons (mN) of force were necessary to platform, phacoemulsification and Im Neuenheimer Feld 400 rupture the capsular bag in the femto- intraocular lens implantation has been 69120 Heidelberg, Germany second laser group compared to 73±22 performed using standard manual The graphic user interface allows easy planning and monitoring. E-Mail: [email protected]

Targeting High-Risk Groups What is the Most Cost-Effective Screening Method for Glaucoma in Areas of Limited Resources?

BEJING – The World Health Organization will be approximately 47.5% sitivity (> or = 80%) and states when patients visit clinics and the disease or its precursor states. ranks glaucoma as the second most and 18.6% respectively of cost per true positive was hospitals. Prevalence of a condition Positive Predictive Value (PPV) of a common cause of blindness after cata- the whole popu-lation of found on all glaucoma means the proportion of patients with test is the proportion of patients with ract, and the most common cause of irre- glaucoma in 2010. China high-risk groups. Hitzl et al. the target disease or pre-disease state positive results who in truth have the versible blindness globally. has the heaviest burden of aimed to report costs, de- in the population tested. Sensitivity is condition for which one is screening. glaucoma. Glaucoma has tection rates, and resources the ability of a test to correctly iden- We presume three populations with he World Health Organization been an important public needed for detection of pri- tify those true positives who have the different prevalence of glaucoma, recommends the criteria which health problem in China. mary open angle glaucoma disease or its precursor conditions. 0.5% (aged 20 years old or above), 5% should be fulfilled before any However, deciding to screen and related diseases in a Specificity is the ability of a test to (aged 40 years old or above), and 20%

T Wan population based screening is under- for glaucoma is a process glaucoma screening pro- correctly identify those true negatives (glaucoma patients’ siblings). When taken. that requires careful consi- Ningli Wang gramme in Salzburg, Aus- or normal persons who do not have the Sensitivity and the Specificity 1. The disease must be an impor- dering of both the benefits tria, over a period of were kept equal (80% and 80% respec- tant public health problem. of early disease detection and inter- 8 years. Direct costs per visit were con- tively) in all three populations, the 2. There must be a recognizable vention and the cost of case finding. siderably higher than those reported in Reference: PPV was increased into 1.97%, latent or early stage, during which The cost-effective studies of POAG the Netherlands or the United King- 17.39%, and 50% respectively. 1. Quigley HA, Broman AT. The number persons with the disease can be iden- screening give us more indications. dom. If a health care provider decides In order to increase the PPV of a of people with glaucoma worldwide in tified before symptoms develop. The study of Boivin et al. indicated to perform a glaucoma screening 2010 and 2020. Br J Ophthalmol screening test, a higher prevalence of 3. There must be an appropriate, that the initial scenario comprised within this setting, the costs for the 2006;90(3):262-267. disease is desirable. So, we can acceptable and reasonably accurate three-yearly POAG screening of detection of a new case are EUR 7250 2. Boivin JF, McGregor M, Archer C. Cost “increase” the presumed prevalence of screening test. subjects aged 40-79. The assumption for definite POAG, EUR 4250 for early effectiveness of screening for primary glaucoma and precursor states by tar- open angle glaucoma. J Med Screen. 4. There must be an accepted and of levels of participation in screening POAG, EUR 1450 for POAG suspect, geting high-risk groups such as the 1996;3(3):154-163. effective treatment for patients with and of compliance with treatment of EUR 5600 for OHT, EUR 2100 for glau- 3. Tuck MW, Crick RP. The cost-effective- elderly, persons with family history of the disease that must be more effec- 75%, and treatment efficacy of 50% coma artefact case, and EUR 156 for a ness of various modes of screening for glaucoma. W tive at preventing morbidity when ini- resulted in a cost of $C100,000 per normal case. The similar studies primary open angle glaucoma. Oph- tiated in the early asymptomatic stage year of blindness prevented. A scenario revealed a trend: screening should be thalmic Epidemiol 1997;4(1):3-17. Fr, 17 February 13.30 – 15.00 hrs 4. Hitzl W, Ortner C, Hornykewycz K et al. than when begun in the later, sympto- in which screening was restricted to carried out in high risk populations. Conference Room B/C Resource use and costs for a glaucoma matic stages of the disease. subjects aged 65-79, with the same We can also use some models to screening program in Austria: an Session: WFS - Public health control strategies 5. The cost of case finding must be input variables, would prevent 81% of show the trend. First, several defi- 8-year review: a cost-consequence for glaucoma: what are the prospects? economically balanced in relation to the cases of blindness prevented with nitions should be clarified. Screening analysis based on the Salzburg-Moor- possible expenditure on medical care scenario 1, at a cost of $C42,000 per usually means population-based fields Collaborative Glaucoma Study. ( Author: Ningli Wang Eur J Ophthalmol 2006;16(1):92-99. as a whole. year of blindness prevented. Screening screening, which is population-based Beijing Tongren Eye Center, Beijing Tongren 5. Thomas R, Parikh R, Paul P, et al. Pop- It is estimated that the number of in the elder population was more cost- detection of disease or pre-disease ulation-based screening versus case Hospital, Capital Medical University, Beijing people affected by primary angle effective. Tuck and Crick compared states. Case Detection, also called detection. Indian J Ophthalmol Ophthalmology and Visual Sciences Key Lab- closure glaucoma (PACG) and primary various modes of screening for glau- opportunistic screening, is the active 2002;50(3):233-237. oratory, Beijing, China open angle glaucoma (POAG) in China coma. The best balance between sen- detection of disease or pre-disease E-Mail: [email protected] 10 | woc 2012 World Ophthalmology News | 2012

The Experience of Jordan Eye Bank Successful Donation Programmes Count on the Help of Religious Leaders

AMMAN - Jordan Eye Bank (JEB) was stress that the religious point of view are known. Banks, International Sight brought great benefits. During 2011, established in 1979, as a national, non- is an important issue in our society. 3. A high likelihood of Registration (ISR) and two short visits by an active team profit institution devoted to the resto- Successful donation programmes success of the transplant Midwest Eye Banks. The from Midwest Eye Banks were made ration of sight. It is based at Jordan Uni- should include identification and operation based on the opin- recipient has to pay for the to JEB to explore its current situation versity Hospital in Amman and funded by engagement of key religious leaders in ion of specialized physicians. shipment and cost of tests and to give advice on eye banking. 4 sectors: Ministry of Health, The Univer- the community to proactively support 4. Total inability of treat- ran on the imported corne- The visits were very fruitful. Midwest sity of Jordan, Royal Medical Services and promote the option of donation. ment in the absence of organ as, on the other hand, local Eye Banks thankfully donated a new and Jordan University of Science and Islam and Christianity support transplant. corneas are provided to specular microscope and provided the Technology. It is run by a committee of organ and tissue donation as one of From 1979 till 1991 we recipients free of charge. required training to our bank techni-

five ophthalmologists representing those the highest expressions of compassion were not able to extract local Bdour Cornea importation has cians. A mutual agreement was signed sectors as well as the private sector. and generosity. The General Iftaa corneas. From 1992 till the Muawyah Al Bdour decreased. As an example; to revise JEB polices and its medical Department of the Ministry of Awqaf end of 2011, more than 2800 here are some figures for standards and to provide JEB a tech- he main Goals and Objectives local corneal transplants were per- the years and number of corneas nical support in order to make it a of JEB are: formed in Jordan according to JEB imported: model in the area. T . to organize and provide records. We attribute this to the clear 2005: 440 corneas basic structure for corneal transplan- “It’s not how much we give statement in 1988 by the religious 2007: 378 corneas Conclusion tation in Jordan, but how much love we put into authorities permitting corneal dona- 2008: 285 corneas As a conclusion, JEB with all the . to spread the awareness of the tion. 2010: 276 corneas efforts made by people with a vision importance and need for local corneal giving.” (Mother Teresa) From 1992 till 2006 the average 2011: 221 corneas of how the world could be a better donation and number of local donation was 95 cor- This decrease in importation goes place has crossed a long way to . to provide corneas for patients in neas/year. The average of local dona- back to the fact that we have been becoming one of the most important need via local donation or importa- and Religious Affairs has issued a tion became 285 corneas/year over extracting more local corneas and we Eye Banks in the Middle East. tion from international eye banks Fatwa on 22 June 1988 permitting the past five years. This was achieved had a large number of keratoconus Needless to say, that with the help suppliers. partial or complete donation of human with the help of different institutions, patients whom we could recently treat of donors, we will keep making a JEB supplies trephines, solution to organs, including corneas, after death the media, JEB Friend Society and with intrastromal corneal rings instead difference and giving hope to all in preserve corneas free of charge to all conditional to the donors tacit and campaigns held by local radio of corneal grafting. need. public hospitals and provides corneal voluntary approval in their lifetime. stations. Two things about eye banking do graft surgical sets almost every other As for after death, the principles of JEB started implementing its new JEB – a Look into the Future, remain the same: the smile recipients year to four major hospitals. In Jordan Islamic Shari’a permit benefiting from role since 1 August 2003 by importing In order to be accepted as a member of have when their sight is restored and the number of patients in need for organs of dead bodies under the fol- corneas for all the health sectors in the International Federation of Eye their gratitude to the generous donors corneal grafting is about 1,300 lowing conditions: Jordan. In order to control the quality Banks, JEB is moving few steps who made it possible. W patients in all health sectors. 1. Verifying the donor’s death. and cost of imported corneas, the towards its target, such as: setting It is worth mentioning here that 2. Donor’s explicit approval during Cabinet made a decision allowing new regulations under the umbrella of Fr, 17 February 15.30 – 17.00 hrs Jordan is a small developing country his lifetime to donate the organs men- only Jordan Eye Bank to import cor- Ministry Of Health, having specular Hall 1 with a population size of about six tioned, or to donate one of them neas, along with controlling the qual- microscope and corneal topographer Session: COR - Eye banking million. In Jordan, 94% of the people voluntarily and at his own will, or the ity of local donation. The imported (Pentacam HR), appointing and are Moslems and 6% are Christians approval of his kin according to corneas exclusively come from: Tissue training staff and interchanging expe- ( Author: Muawyah Al Bdour that live in peace together. With inheritance hierarchy if his identity is Banks International (TBI), North Caro- rience. JEB had a good experience Director, Jordan Eye Bank regards to local corneal donation, we known and his family and relatives lina Eye Banks, Heartland Lions Eye with Midwest Eye Banks which has E-Mail: [email protected]

Most Useful for Non-Invasive Examinations Corneal Imaging using Three-Dimensional Anterior Segment OCT

OSAKA - The OCT technology rior segment, but also for 3D images of the anterior segment of will play an increasingly planning and evaluating the eye more precisely. For example important role as non-invasive anterior segment surgery the SS-1000 (Tomey Corporation, and quantitative modality for such as DSAEK and DALK. JAPAN) has a vertical resolution of 10 examining the anterior seg- The resolution in vertical µm with 30,000 A-scans per second ment of the eye. direction is 18 μm and the for 16mm diameter. speed of the A-scan is 2000 We had the chance to develop an ince optical coherence scans per second with the OCT-based corneal topographer with tomography (OCT) was 1,310 nm time-domain OCT. Figure 1: Cross-sectional image the SS-1000 to solve problems of cur-

introduced as a non- (3) Maeda On the other hand, high- with 840 nm SD-OCT in a patient rently available corneal topo- S with bullous keatopathy: The bulla 3,4 contact imaging method Naoyuki Maeda, MD er resolution (5 μm) and graphers . Figure 2 shows the exam- that provides detailed cross- faster speed of the A-scan formation and Descemet’s fold ple how to compare topographic find- sectional images of internal structures (26000 scans per second) can be were recognized clearly. ings among a Placido-based corneal of the tissues1, OCT has been attracting obtained with the 840 nm spectral- topographer (TMS-4N, Tomey), a a great deal of attention in the field of domain OCT (RTVue-100, Optovue Scheimpflug-based corneal topo- Ophthalmology. It caused a paradigm Inc., Fremont, CA). Bowman’s layer grapher (Pentacam HR, Oculus), and a shift in diagnosing and treating retinal can be identified as the parallel lines, Figure 2: Comparison of topographic appearance in a OCT-based corneal topographer (SS- diseases. and the thickness profile of epithelial patient with moderate keratoconus among three corne- 1000, Tomey). In this eye with mild The first report of OCT imaging of layer and stromal layer of the cornea al topographers. (cited from Ref 3) keratoconus, one can find all the ante- the cornea and the anterior segment can be analyzed separately with SD- Note that Placido-based (left), Scheimpflug-based rior axial power maps revealed similar of the eye was published in 19942. The OCT, although it is difficult to obtain (center), and OCT-based (right) reveal similar patterns. inferior steepening. Also, elevation time-domain OCT at 1,310 nm images clear enough to separate the maps of the anterior and posterior (Visante, Carl Zeiss Meditec, Inc., epithelial layer from the stroma in a corneal surfaces and the pachymetry Dublin, CA) has become commercially normal cornea with TD-OCT. The map resemble each other between available for cross-sectional images of details of bullous keratopathy (Figure Pentacam and SS-1000. the cornea, anatomic structures of the 1) or epithelial ingrowth under the The Placido-based topographer iridocorneal angle, and anterior cham- LASIK flap was clearly shown by the uses mire images produced by the ber biometry. The anterior segment of high-resolution images with high reflex in pre-corneal tear film and it is the eye can be visualized and quanti- magnification using SD-OCT. difficult for the videokeratoscope to fied non-invasively in the clinic. The introduction of the 1310nm digitize heavily distorted mire images Anterior segment OCT (AS-OCT) is swept-source OCT, that is categorized in eyes with severe irregular astigma- now frequently used not only for as another type of Fourier-domain diagnosing the pathology of the ante- OCT, empowered us to reconstruct the continued on page 11 ( World Ophthalmology News | 2012 woc 2012 | 11

( continued from page 10

tism. The OCT-based topographer is Early Visual Rehabilitation Prevents Depression resistant to the severe distorted corne- as because of the sequential acquisi- Results of a Randomized and Controlled Pilot Study in Patients with AMD tion of cross sectional images. With the OCT corneal topographer, TÜBINGEN – Adequate and in-time vision We included patients suffering from was no statistically significant differ- topographic analysis can be done rehabilitation has a positive effect on AMD in both eyes and best corrected ence between the two groups regard- even in the area where severe scar or secondary depression due to AMD. visual acuity not better than 0.2 to make ing age, gender, education, cognitive edema exists in the corneal stroma. sure that reading was not possible any- status, depression and quality of life. This may be the potential advantage n several studies is was reported more without low vision aids. None of Best corrected visual acuity did not of the OCT corneal topographer over that age-related macular degene- the patients had undergone visual reha- change in the three months interval. conventional instruments in terms of I ration (AMD) has a negative bilitation before. We recruited patients Reading speed in the rehabilitation the application for evaluating various impact on quality of life (Mitchell J et into two study arms: a rehabilitation group, as expected, improved in a clin- types of corneal diseases or corneal al., Health Qual Life Outcomes group, which was provided with low ically relevant matter from 44 words surgeries. In addition, the OCT-based 2006;4:97; Wahl HW et al. Ophthalm- vision aids at the first assessment, and a per minute up to 59 words per minute. corneal topographer has the potential ologe 2008 105:735-743; Casten RJ control group which was provided 3 Because of the small number of patients to analyze anterior and posterior parts et al. Curr Opin Ophthalmol months later at second assessment. All included, this difference did not of lamellar surgeries separately, as 2004;15(3):181-183). It also often patients underwent clinical ophthalmo- become statistically significant. Dr. Anne Mielke (left), investigator and Prof. OCT can detect the interface following leads to secondary depressive disor- logical examination and psychological In terms of the psychological testing Dr. med. Susanne Trauzettel-Klosinski DSAEK, DALK, FLEK (Femto-second ders and to cognitive impairment testing at first and second assessment. we observed changes from visit one (right), supervisor and presenting author of Laser enabled Keratoplasty), and (Augustin A et al. Invest Ophthalmol We measured reading speed of patients until visit two in three test items: the study. LASIK (Laser in situ Keratomileusis). in the rehabilitation group at both . Median of the ADSL was 3 points The OCT technology will play a Members of he study group: assessments, of control group only at diminished in the rehabilitation group Testscore increased 13 points in more and more important role as one 1Mielke A, 2Wirkus K, 2Niebler R, second assessment because the control whereas it increased 3 points in the rehabilitation group and decreased of the most useful non-invasive and 2Eschweiler G, 1Nyugen NX, group did not get rehabilitation before control group, which implies that 5 points in control group, denoting an quantitative modalities for examining 1Trauzettel-Klosinski S and therefore could not read at first patients of the rehabilitation group upturn of coping with social roles in the anterior pathology of the eye, 1Vision Rehabilitation Clinic assessment. Psychological testing was became less depressive whereas the rehabilitation group. The interac- planning and evaluating anterior seg- and Research Lab, Centre for executed via Geriatric Depression Scale, patients of the control group became tive effect of change was statistically ment surgeries in the near future. W Ophthalmology, University of German version of CES-D-Scale (ADSL: even more depressive throughout the significant in all items (ADSL Scale p Tübingen, Germany general depression scale), Mini-Mental observation period (figure 1.). = 0.039, Dementia Detection Test p = Sat, 18 February 08.30 – 10.00 hrs . 2Department for Psychiatry State Examination, Dementia Detection In the Dementia Detection Test 0.037 and ­NEIVFQ 25 item “exercise of Hall 1 und Psychotherapy, University of Test and Quality of Life was determined scores increased 2 points in the reha- social roles p = 0.035), which impli- Session: COR - Advances in Corneal Imaging Tübingen, Germany by National Eye Institute Visual Func- bilitation group and diminished cates, that the rehabilitation does not tion Questionnaire (NEI-VFQ 25). 3 points in the control group, meaning only prevent a further decline into ( Author: Naoyuki Maeda, M.D. We included 22 patients, who were that patient’s mental situation depressive symptoms but also is asso- Department of Ophthalmology Vis Sci 2007;48(4):1498-1503; Pham randomly assigned: 11 were recruited improved in the rehabilitation group. ciated with an improvement in mood. Osaka Univ. Graduate School of Medicine TQ et al. Gerontol 2006;52:353-358; for the rehabilitation group and 11 as . Also the subitem “exercise of We found encouraging indications Room J7, Yamadaoka 2-2 Rovner BW et al. Am J Geriatr Psychi- controls. Average age was 79 (range social roles” of the NEIVFQ 25 changed that adequate and in-time vision reha- Suita, 565-0871, Japan atry 2009 17(7):574-81). If we have a 68-85) years. At first assessment there in a divergent manner: bilitation has a positive effect on se- E-Mail: [email protected] look on the according data, we find condary depression due to AMD. We that there is a prevalence up to 33 per- are confident to confirm positive cent of AMD-patients who additional- effects of visual rehabilitation after a ly suffer from depression. Depression longer observation period in the itself even may deteriorate patients’ intended main study with a larger References perception and can worsen patients patient cohort. If we can again proof mental situation (Rovner BW et al. the prevention effect of visual rehabili- 1. Huang D, Swanson EA, Lin CP et al: Arch Ophthalmol 2002; 120(8):1041- tation on secondary depression this Optical coherence tomography. Sci- ence 1991;254(5035):1178-1181. 1044; Clemons TE et al. Arch Ophthal- would be of a great social and econom- 2. Izatt JA, Hee MR, Swanson EA et al.: mol 2006;124(4):537-543). ic relevance. W Micrometer-scale resolution imaging The access to professional help of the anterior eye in vivo with optical such as psychological support or low Fr, 17 February 8.30 – 10.00 hrs coherence tomography. Arch Ophthal- vision rehabilitation in general is poor Conference Room B/C mol 1994;112(12):1584–1589. 3. Maeda N.: Optical coherence tomogra- (Wahl HW et al. Ophthalmologe 2008 Session: Depression and visual impairment phy for corneal diseases. Eye Contact 105:735-743). We decided to create a Lens. 2010; 36(5):254-259. randomized controlled pilot study to ( Authors: Dr. Anne Mielke, 4. Nakagawa T, Maeda N, Higashiura R investigate the influence of low vision Prof. Dr. Susanne Trauzettel-Klosinski et al.: Corneal topographic analysis in rehabilitation on the occurrence of Vision Rehabilitation Clinic and Research Lab patients with keratoconus using 3-dimensional anterior segment opti- secondary depressive disorders related Centre for Ophthalmology cal coherence tomography. J Cataract to AMD. For this study we cooperated Figure 1: ADS-L score_A (general depression scale) at 1st and 2nd visit. The rehabilitation University of Tübingen, Germany Refract Surg 2011;37(10):1871-1878. with our colleagues in the Department group became less, the control group more depressive. The interactive effect of change E-Mail: susanne.trauzettel-klosinski@med. of Psychiatry and Psychotherapy. was statistically significant. uni-tuebingen.de

Toric Multifocal IOLs or Bioptics? The Correction of Astigmatism in Cataract and Refractive Surgery

MANNHEIM - The correction of corneal the surgery must be addressed more raised here is: Which technique is cataract or refractive lens surgery, astigmatism on the cornea would be astigmatism is a significant issue in cata- precisely than in a monofocal IOL. As preferable? Shall we use a toric multi- which means any astigmatism present ideal. But there are other issues. ract and refractive surgery. about 60-70% of eyes present with focal IOL or shall we combine laser now must be corneal. It seems intui- corneal astigmatism of more than refractive corneal surgery and implan- tive that corneal astigmatism should Possible Side Effects ultifocal IOLs are designed 0.5 D before surgery, the correction of tation of a multifocal IOL, a technique be corrected on the cornea, and opti- First, there are the side-effects of laser to replace glasses. This astigmatism is a significant issue both named “bioptics”? Shall we use other cally speaking this is correct. Correct- refractive corneal surgery, namely dry M necessitates a perfect in cataract and refractive surgery. options such as corneal incisions? ing corneal astigmatism on another eye syndrome in LASIK and haze in refractive outcome, which means plan, away from the cornea, induces surface ablation. Second, performing emetropia. To achieve good vision at Which Technique is Preferable? Danger of Image Distortion image distortion. Just remember the laser refractive corneal surgery distance and near, the refractive error Corneal astigmatism can be corrected As always, there is no simple answer image distortion that occurs when requires another surgical procedure, in must be within +/- 0.5 D, both for using corneal incisions, corneal laser to this question, otherwise there would using spectacles to correct astigma- addition to the IOL implantation. The sphere and cylinder. Multifocal IOLs refractive surgery such as PRK/LASEK be no point in writing an article or tism as compared to contact lenses. patient has to come again, and there are thus much less tolerant to residual or LASIK, and toric IOLs. Toric multi- giving a presentation on this topic! To The image distortion becomes more are the general risks of surgery. Thus, astigmatism than monofocal IOLs, focal IOLs are now available from a start, let us remember that the astig- significant the higher the attempted from an overall perspective, a toric which means that any astigmatism number of companies including matism to be corrected is corneal. The correction is. If optics would be our existing preoperatively or induced by Alcon, Zeiss, and others. The question crystalline lens is removed during the only concern, correcting corneal continued on page 12 ( 12 | woc 2012 World Ophthalmology News | 2012

( continued from page 11 two arcuate incisions in addition to multifocal IOL, which corrects 1.5 D of results in a certain number of “not tive, as corneal astigmatism is correct- the main incision, if I place the main astigmatism at the corneal plane, and perfect” refractive outcomes, which ed at the corneal plane. However, toric multifocal IOL seems to be an excel- incision away from the steep meridi- I will use arcuate laser incisions to need to be addressed. A corneal multifocal IOLs are the preferred lent choice to correct both astigma- an. The use of the femtosecond laser correct the remaining 1.5 D of corneal arcuate incision can, of course, be option, because they require one sur- tism and sphere (and presbyopia, by in lens surgery therefore enables me astigmatism. I believe that this repeated, or enlarged, and a gical procedure only in most eyes and the way). to correct corneal astigmatism by per- approach minimizes optical side misaligned toric IOL can be rotated. still provide an excellent refractive forming arcuate corneal incisions at effects and maximizes predictability Adding or enlarging an arcuate cor- outcome. Toric multifocal IOLs may be Use of the Femtosecond Laser the time of lens surgery. I use this of refractive outcome. neal incision, however, is not very combined with corneal relaxing inci- My current approach is a combination approach routinely in eyes with cor- What about bioptics? Is there still a predictable, and re-aligning a toric sions (e.g., laser refractive lens sur- of the above and yet another tech- neal astigmatism of less than 2 D. place for laser refractive corneal sur- IOL requires another intraocular pro- gery with a femtosecond laser) to nique. I implemented laser refractive Corneal astigmatism of 2 D or more gery in combination with IOL implan- cedure. I therefore prefer to use laser minimize optical side effects and lens surgery with an intraocular fem- can still be corrected on the cornea tation? I believe there is, although I do refractive corneal surgery in these maximize refractive outcome. W tosecond laser in July 2011. I use the using arcuate incisions alone, but the no longer use bioptics as a pre- cases. Typically, I will perform LASIK Alcon LenSx femtosecond laser, which incisions will induce a significant planned procedure if a toric multifocal with a femtosecond laser. I always Thu, 16 February 13.00 – 14.30 hrs enables me to perform corneal inci- amount of corneal irregularity as they IOL is available. In my opinion, biop- place my arcuate incisions at a radius Hall 1 sions both for entry into the eye and are typically performed at a radius of tics is therefore indicated whenever a of 4.5 mm (9 mm diameter), which Session: Presbyopia correction: where are we? for astigmatism correction, capsu- 4.5 mm (9 mm diameter), or even less, toric multifocal IOL is not available leaves space for an 8.5-mm flap, lorhexis, and lens fragmentation and and therefore not too far away from for the attempted correction, or in all which is my preferred choice. I prefer ( Author: Michael C. Knorz liquefaction. Using this femtosecond the center of the cornea. Because of cases of retreatments due to unexpect- LASIK, but this is a personal choice. Professor of Ophthalmology laser, I always position my main inci- this irregularity, I prefer to split the ed refractive outcome. The predicta- PRK/LASEK work just as well and will Medical Faculty Mannheim sion on the steep axis of the cornea (or correction of corneal astigmatism of bility of IOL calculation formulas is give the same results. of Heidelberg University at 12 o´clock, if there is no astigma- 2 D or more between corneal arcuate not 100%, the outcome of arcuate Mannheim, Germany tism present). I combine this main incisions and a toric multifocal IOL. incisions varies considerably, and Conclusion E-Mail: [email protected] incision with an arcuate incision on For example, if corneal astigmatism of toric IOLs can, as of today, not be In summary, bioptics are the better Dr. Knorz is a consultant to Alcon LenSx, Ft. the opposing half-meridian, or I use 3 D is present, I will implant a toric implanted “on axis” in all eyes. This choice from a purely optical perspec- Worth, TX, USA

Management of Complicated Femtosecond Laser Flaps Problems often Linked to the Surgical Technique

IZMIR – The femtosecond laser has docu- cient. In two cases I was unable to way into the anterior sweeps, the tip of the spatula Previous Penetrating mented advantages in creating the cor- achieve suction in spite of several chamber by dissecting must avoid the visual axis. Keratoplasty and RK neal flap. Complications are rare and not attempts. In these cases, I performed through the cornea and It is possible to make femtosecond as devastating as some of microkerato- the cut by increasing the pressure and trabecular meshwork. Hinge Tear laser flaps larger or smaller than the me-associated complications. manually holding the suction ring These bubbles, because of This can happen when the graft in corneas with previous pene- without any complications. the supine position of the spatula is inserted at the trating keratoplasty. Lifting the flap in he most crucial step in LASIK patient interfere with the interface to initiate the lift- cases where the flap is larger than the is the creation of the corneal Gas Bubbles patient fixation and the ing of the flap. In such a graft and in corneas with RK is the flap, as anything less than a The most common problem is the laser autotracking. In such case, I leave a thin island of most difficult part because the graft

T Kaskaloglu (4) perfect flap jeopardizes the success of opaque bubble layer which interferes cases simple dilatation of unseparated flap near the interface or RK incision may separate. the operation. Although the micro- with the laser auto tracking. In these the pupil usually solves the Mahmut Kaskaloglu hinge tear and separate the One should dissect the flap very care- keratome has long been used success- cases, it is best to wait until the problem with the auto rest of the flap to prevent fully in order to preserve the integrity fully for flap creation, recently, the bubble layer diminishes to a level tracking, or one can wait a few hours extension of the hinge tear. I separate of the cornea. If vertical gas break- femtosecond laser has found exten- which does not interfere with the or ask the patient to come the next this island after complete separation through happens at the site of RK cuts, sive use for corneal flaps. Having had excimer laser auto tracking. Gentle day. of the flap then place the hinge and lifting the flap is not recommended excellent results with the microkerato- massage of the corneal surface with a Vertical gas breakthrough may dry the edges. If the hinge is totally because of the risk of a button hole. me in our clinic, we initially felt that spatula may shorten the time by help- happen in corneas with scars that torn, the flap is separated in such a we did not need the femtosecond ing the absorption of the bubbles. caused a physical defect on the Bow- way that a hinge is left at 180 degrees Unliftable Flap and laser. However, a few weeks after the Sometimes the gas bubbles find their man’s membrane. During the femto- from the original hinge. Nondissected Islands installation of the femtosecond laser second raster phase, this can be recog- This is a rare complication where the we were so pleased with its results nized as a black spot. We avoid lifting Incomplete Side Cut interface is insufficiently dissected and that it became our method of choice, such flaps to prevent buttonholes. The The reason for this complication is the it is difficult to separate the flap. It leaving the microkeratome as a back- best method of avoid vertical gas uneven cone position in the suction may be possible to separate the flap up instrument. The femtosecond laser breakthrough is to make the flap ring, causing uneven applanation using a little bit more force during the has documented advantages over the thicker. If the scar is not recognized during the procedure. The surgeon can lifting. Using too much force should be microkeratome. Mainly, it is more preoperatively and the flap is lifted notice this during the laser application avoided since it may cause a rupture of precise and predictable, also the com- causing a button hole, after the or later at the excimer laser while the flap. In such cases it is advisable to plications associated with the femto- excimer laser, the flap is repositioned lifting the flap. In our practice, if the postpone the surgery to a later date second laser are not as devastating as and carefully dried then a contact lens partial cut is less than 45 degrees, we and attempt again with the femto- some of the complications associated Flap side tear. is applied. We have had several such do not attempt a second side cut, even second laser or the microkeratome. with the microkeratome. Our expe- cases without any negative conse- if we see it during the flap creation. rience is limited to the IntraLase FS 30 quences. Instead, we dissect the flap from where Conclusion and the IntraLase FS 60 (Abbott the side cut is proper and then care- The complications of femtosecond Medical Optics, Santa Ana, CA). Flap Tears fully lift the uncut portion with the laser flaps are rare and they can usu- The most serious complication associ- aid of a McPherson forceps. This is not ally be handled by the surgeon with- Suction Loss ated with the femtosecond laser flaps as difficult as it sounds because there out further consequences for the This is an occasional complication is cutting the flap with the spatula. usually is a partial side cut. Although patient. These complications are not where the suction ring loses vacuum This is usually a surgeon-related com- the relatively irregular edges increase related to the femtosecond laser during the flap creation. Tight orbits, plication. To prevent this one should the risk of epithelial ingrowth, we instrument but to the surgeon. The lid squeezing and faulty positioning check the tip of the spatula carefully have not seen any. application of good surgical technique are the main causes. If suction loss Raster phase in a case with previous kera- for any defects before entering the usually prevents such complications. happens during the raster phase, we toplasty. interface. If this happens peripherally Decentered Flap reapply a different suction ring and it has no effect on the vision of the Extreme attention should be paid to Sat, 18 February 10.30 – 12.00 hrs the same cone and repeat the proce- patient. However, if the flap cut is at center the flap on the cornea. Hall 7 dure. If the suction is lost during the the pupillary axis, it compromises the Marking the center of the cornea Session: IVI - Refractive surgery: complications side cut we repeat the side cut only by visual quality. In such a case, the flap before applying the suction ring and management reducing the diameter by 0.2 mm, should be placed and dried carefully. helps to better centration, however it using the same cone and a different After making sure that it is well is possible to achieve perfect centra- ( Author: Prof.Dr.Mahmut Kaskaloglu suction ring. Sometimes the suction is adhered, a contact lens is placed on tion without marking. Kaskaloglu Eye Hospital lost during the last second of the side the cornea. In anticipation of such a Since the femtosecond corneal 1400 sokak 10 cut. In this case we do not repeat the complication, the surgeon should se- flaps are usually over 9mm, only Alsancak,Izmir,Turkey side cut, because in our experience, parate the flap as a whole or if he or extreme decentration can be clinical- E-Mail: [email protected] the side cut is almost always suffi- Inferior hinge in a case with the hinge tear. she prefers to separate at multiple ly significant. www.kaskaloglu.com