Building India's World-Class Eye Hospital

fEBRUARY 2014 # 05

Upfront In Practice NextGen Profession Just a quick dip: making Hot tips on anterior and Will you print out a Marketing your cataract/ stem cells in an acid bath posterior capsulorhexis new retina in the future? refractive practice

10 29 – 31 38 – 40 44 – 47

Building India’s World-Class Eye Hospital

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03 Online This Month Upfront Feature

10 STAP in the Name of Love 16 How to Build a World-Class 07 Editorial Eye Institute The Philanthropic Ophthalmologist 11 This Month in Business Gullapalli Rao describes the By Richard Gallagher origins, development and impact 12 Google’s Glucose Gadget of the eye institute that he created in his home country, India. 08 Contributors 13 Questioning the “Critical Period”

14 Ranibizumab Reality Bites On The Cover In Practice 15 Ophthalmologists are Healthy, fEBRUARY 2014 # 05 Vintage ornamental pattern. Wealthy and Wise 26 The Perfect Anterior Capsulorhexis

10 29 – 31 38 – 40 44 – 47 Image courtesy of Getting the right shape and Building India’s World-Class Eye Hospital

Gullapalli Rao tells the story of the LV Prasad Eye Institute 16 – 23 shutterstock.com. right size generates optimal optical outcomes, says Johan Blanckaert.

ISSUE 05 - FEBRUARY 2014

Editor Mark Hillen [email protected]

Editorial Director Richard Gallagher [email protected]

Graphic Designer Marc Bird [email protected]

Managing Director Andy Davies [email protected]

Director of Operations Tracey Peers [email protected]

Publishing Director Neil Hanley [email protected]

Audience Development Manager 29 Don’t Fear the Posterior Capsule Profession Tracey Nicholls Marie-José Tassignon argues that [email protected] a rethink on the surgical 44 Premium Practice Promotion Digital Content Manager approach to posterior Laura Hobbs illustrates how David Roberts capsulorhexis is required. patient engagement and [email protected] education help market 32 Great Expectations Fuel one’s practice. IOL Inclinations Are advances in IOL and 48 Educational Excellence Published by phacoemulsification technology – For Patients Texere Publishing Limited, driving demand for cataract Textbooks are so 20th Century. Booths Hall, Booths Park, surgery more than medical need? Mark Hillen looks at what 3D Chelford Road, Knutsford, Cheshire, electronic patient education WA16 8GS, UK systems can do. General enquiries: www.texerepublishing.com NextGen [email protected] +44 (0) 1565 752883 36 Cataract Benchmarking Sitting Down With [email protected] Mining the cataract literature to uncover who’s publishing what, 50 With Walter Wrobel, CEO/ Distribution: where, and in what language. President, and Reinhard Rubow, The Ophthalmologist distributes and CFO, Retina Implant AG. 17,934 printed copies and 7,295 electronic copies to a targeted 38 Inkjet Interventions European list of industry Keith Martin envisages a future in professionals. which healthy stem cells are sprayed ISSN 2051-4093 on during retinal surgery. Precision

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ophthalmologist working.indd 4 14/01/2014 12:03 The Philanthropic Ophthalmologist Editorial Be it battling blindness one patient at a time or changing global healthcare policies, ophthalmologists demonstrate admirable altruism.

phthalmologists seem to have it all – according to the Medscape Physician Lifestyle Report 2014. Out of 26 medical specialties, ophthalmologists figure among the healthiest, wealthiest and happiest, and rank highest overall in lifestyle satisfaction (see the article on page 15). OI hope that the feel-good factor extends beyond the United States, where the survey was performed, to embrace the ophthalmology community across the globe; I have a feeling that it does. One facet of lifestyle that the report did not delve deeply into is philanthropy; if it had, it is likely that ophthalmologists would have excelled in this category too. Deep within ourselves, we all have a desire to care for, nourish, develop and enhance the lives of less fortunate fellow humans. For most people, that urge is satisfied by giving money and/or time to the causes closest to their hearts. For physicians, the contribution can be much more impactful and rewarding. In the case of ophthalmologists, the impact and reward are off the charts. Nine out of 10 people who are visually impaired live in developing countries; in eight out of 10 cases, that visual impairment could be avoided or cured. This explains why so many ophthalmologists spend part of their vacation time in developing countries, removing cataracts and performing other surgical procedures in an almost production-line manner. These traveling ophthalmologists have a transformational effect upon the lives of every patient that they treat. It’s a great humanitarian gift, requiring a combination of years of postgraduate ophthalmology training and funding from organizations like Sightsavers and The Fred Hollows Foundation. Unfortunately, despite best efforts, the problem remains a massive one, with most of the people who would benefit from surgery not being treated. Another interpretation of the philanthropic ophthalmologist is provided by Gullapalli Rao. His narrative of building the LV Prasad Eye Institute in Hyderabad, India is this month’s feature, and it is stirring stuff (see page 16). Over half of the institute’s patients are treated free of charge – a proportion that rises further in the rural outreach centers. Battling blindness in developing countries is something that is being attacked from both ends. Efforts like the WHO and IAPB’s VISION2020 initiative have established infrastructure and systems for the treatment of diseases that can lead to avoidable blindness, like cataracts or ocular infections. Those running these efforts also demonstrate a great sense of kinship with their fellow man. Health, wealth and happiness are what we all want in our lives. It seems that a great number of ophthalmologists also go out of their way to share this good fortune with others. Long may it continue!

Richard Gallagher Editorial Director Contributors

Gullapalli Rao The LV Prasad Eye Institute, a world-renowned eye hospital in Hyderabad, India, is the brainchild of Gullapalli Rao. Rao left India in 1974 to train in the USA; despite enjoying his time there immensely, he returned home in 1986 to pursue his dream. In this issue, he recounts the origins of the hospital and describes his motivation, his hopes for the future and the potential to apply the institute’s approach in the US. See page 16.

Marie-José Tassignon With four patents that have been implemented in clinical practice, Marie-José Tassignon is a keen proponent of the need for ophthalmologists to understand physiology and the physics of optics. She is Chief and Chair of the Department of Ophthalmology of the Antwerp University Hospital – an institute where she is also Medical Director. One of her patents, for a bag-in-the-lens IOL, features in her article on rethinking the surgical approach to posterior capsulorhexis, which can be found on page 29.

Johan Blanckaert Johan Blanckaert is a surgeon with an appreciation of beauty. He co-owns an art gallery, Emergent, in Veurne, Belgium and spends his spare time at art and cultural events. He is the Director of the Eye and Refractive Center in Iper, Belgium, a Consultant Ophthalmologist at UZ Leuven and the current President of BBO- UPBMO, the Belgian Professional Union of Medical Specialists in Ophthalmology and Ocular Surgery. Blanckaert shares his experience with anterior capsulorhexis in the article on page 26.

Laura Hobbs A practice-development specialist who works in the US and Europe, Laura Hobbs was one of the presenters in the 2013 ESCRS Practice Development Program. Having held the positions of Practice Development Manager and Director of Marketing at high-volume refractive clinics in the US, Hobbs has extensive experience in improving practice efficiencies, marketing, and patient education, which she brings to bear on her article on page 44.

10 Upfront

author of the textbook, Regenerative STAP in the Medicine, to find out what it means for Upfront the clinical development of stem cell- Name of Love based therapies.

Reporting on the An unexpected and simple What is the big breakthrough here? innovations in medicine advance has made stem cell Treating cells with acid does not production much easier and involve direct manipulation of genes and surgery, the safer. Do STAP stem cells bring or require the transfections of genetic research policies and the treatment, even cure, of materials. There is, therefore, a greatly personalities that shape ocular disease a lot closer? reduced risk of the process turning a patient’s cells into something nasty, like ophthalmology practice. Stem cells are not easy to produce. a neoplasm, for example. Unless your parents arranged to harvest We welcome suggestions some from your umbilical cord at birth, Will it save time? on anything that’s embryonic stem cell-based therapies It is a little faster, but the time- have the disadvantage of not being consuming step is verification of impactful on yours, risking rejection just like any pluripotent stem cells and their ophthalmology; heterogeneous transplant. The first differentiation towards building the please email alternative was to create stem cells by tissue you want, rather than making nuclear transfer into oocytes, or by them in the first place. Although there [email protected] fusion with embryonic stem cells. Then, is a cost saving. in 2006, Takahashi and Yamanaka (1) showed that differentiated, adult Does it mean that stem cell therapies cells could be reprogrammed by the will hit the market sooner? insertion of four genes. Such cells Ultimately, the time to ‘market’ depends could differentiate into any cell type on safety testing, and that will have to be of the body and were termed induced done whatever the method of making pluripotent stem cells (iPS). pluripotent cells. This method looks That has been the state of the art, until safer, so may have a higher probability now. In a Nature paper published in of passing those tests, but it’s important January, Haruko Obokata and colleagues to remember that pluripotent stem cell took differentiated cells from a week- generation is measured in days or weeks old mouse, cultured them in a low-pH depending on what method is used (5.7) cell culture medium and created (this one or a traditional one), whereas Stimulus-Triggered Acquisition of clinical trials are measured in years. Pluripotency (STAP) cells (2). While Saving a few weeks does not really have STAP cells are hard to culture, they can much of an impact. form any cell type that an embryo can, including the trophoblasts of the placenta. How significant are the findings for stem- Slight changes to the culture medium cell research and medicine in general? produced STAP stem cells, which are They may alter our understanding of pluripotent, proliferative, and can develop what return to pluripotent stem cell into any adult mouse cell type. state is – even raising the question of Stem cells from an acid bath might whether ‘traditional’ methods (1) also seem too good to be true. We spoke to work by stressing cells. We may also Jamie Davies, Professor of Experimental have misunderstood the robustness/ Anatomy at Edinburgh University, and fragility of the differentiated state, and Upfront 11

The Month in Business

Carl Zeiss and Aaren buy, Alimera raise working capital and Novo A/S make a milestone payment to Ophthotech for Fovista.

Already 2014 has seen a number of Figure 1. How to make a stem cell. Top. Reprogram differentiated cells to become induced big business decisions being made pluripotent stem (iPS) by the introduction of four transcription factors. Bottom. Short-term exposure in ophthalmology: of differentiated cells to low a pH solution generates stimulus-triggered acquisition of pluripotency (STAP) cells. STAP cells barely proliferate, culturing medium them in a pluripotency-promoting • Carl Zeiss Meditec AG medium produces STAP stem cells, which have the same properties as iPS cells. purchased the American IOL manufacturer, Aaren Scientific, we could now have fresh insight into exciting to basic scientists and may for US$70 million. the association between chronic tissue open the door to new discoveries, and • Niche generic pharmaceutical injury and the risk of neoplasia – maybe what is useful for fast and efficient company, Akorn, acquired all cells become stem-like in response to generation of therapies. The slow and rights for Betimol (timolol the stress of chronic injury, and this part vastly expensive path to regulatory ophthalmic solution) from Santen. of the step to founding a neoplasm is approval remains. A new design of • Alimera Sciences raised not actually a story of genetic mutation. running shoe may be half the cost of approximately US$37.5 the old one and take half the time to put million, “as working capital for And its significance for the future of on, but this has little effect on the effort the commercialization of Iluvien stem cell therapies? demanded by a marathon. MH in Europe and the ongoing pursuit If all of this holds up, and especially if of FDA approval in the United a range of stressors of cells works, then References States”, according to Dan Myers, a lot of intellectual property in the 1. K. Takahashi, S. Yamanaka, “Induction of Alimera’s President and CEO. iPS field can be bypassed, potentially pluripotent stem cells from mouse embryonic and • Ophthotech reached an allowing more competition in the field. adult fibroblast cultures by defined factors”, enrolment milestone in the phase But beware of hype. This is genuinely Cell, 126, 663–676 (2006). doi:10.1016/j. III safety and efficacy trial of exciting – folk in my lab dropped what cell.2006.07.024. Fovista (E10030), an anti-platelet- they were doing to discuss it, and to 2. H. Obokata et al., “Stimulus-triggered fate derived growth factor (PDGF). come banging on my door to show me conversion of somatic cells into pluripotency”, Making the milestone triggered the paper. There is not, though, a one- Nature, 505, 641–647 (2014). doi:10.1038/ a US$41.7 million payment from to-one relationship between what is nature12968. its partner, Novo A/S. MH 12 Upfront

Google Glass, the Google Driverless Car to make the project a commercial reality. Google’s and Project Loon, which uses balloons in Google X’s project is not the first the stratosphere to deliver internet to all. wearable contact lenses that senses Glucose Gadget The rationale for the contact lens is blood glucose levels in this way. Similar this: most diabetic patients find it hard technology was developed some years Google is developing contact to control their blood glucose levels, and ago by researchers in Tokyo, Japan (2), lenses that will help patients fingerprick glucose monitoring is both and a group at Malmo University in monitor their glucose status. painful and bothersome. Poor glucose Sweden have now developed a glucose- The technology is not entirely control leads to myriad diseases and sensing contact lens that uses tears as new, but the company’s complications, so improved monitoring fuel (3). But, as with Google Glass, the infrastructure, experience and of blood glucose is a step in the right Google X strategy is to take an existing muscle suggest that it could direction. technology and refine it. The company have a substantial medical and It has long been known that glucose has the resources and ambition to get the commercial impact. levels can be measured in tears. Google product to market, and the infrastructure researchers have combined this to cope with the data avalanche that Google’s X laboratory, according to knowledge with nanotechnology – tiny millions of people wearing these contact its co-supervisor, Astro Teller, aims to processors, tiny glucose sensors, and tiny lenses will produce. This may prove “improve technologies by a factor of 10” antennae for both data and power transfer. crucial for its success. The medical device (hence the X) and to develop “science- They’ve produced prototype contact market is not an easy one to succeed in, fiction-sounding solutions.” The recently- lenses that incorporate red and green as the demise of non-invasive glucose- announced Google contact lens (1) is LEDs to give wearers instant feedback on sensing device manufacturers like C8 the fourth X-project described, joining their glucose levels, and they are readying MediSensors, SpectRx and Fovioptics shows. If anyone can bring the device to vision deprivation are immediately after the mass market and make an impact, birth, although at 24 months the initial it’s Google. MH critical period is considerably longer than in cats. It was thought to be crucial that References ocular abnormalities are identified and 1. “Introducing our smart contact lens project”. resolved during the first two years of life. http://googleblog.blogspot.co.uk/2014/01/ Plasticity in the visual system progressively introducing-our-smart-contact-lens.html diminishes thereafter and, by the age of 2. S. Iguchi et al., “A flexible and wearable biosensor eight, appeared to be almost gone. The Figure 1. Simulated views of an abstract painting for tear glucose measurement”, Biomed conventional wisdom is that if diseases depicting the development of pattern vision Microdevices, 9, 603–609 (2007). like amblyopia are not treated before eight following early and extended blindness. Left 3. M. Chu et al., “Biomedical soft contact-lens sensor years of age then the opportunity to save panel: poor spatial resolution and contrast for in situ ocular biomonitoring of tear contents”, sight is completely lost. perception immediately after cataract surgery. Biomed Microdevices, 13, 603–611 (2011). doi: Conventional wisdom, however, may Middle panel: Enhancement of contrast 10.1007/s10544-011-9530-x. not to be correct, according to findings sensitivity after six months. Right panel: Original from Project Prakash, a scientific image.Image courtesy of Luis Lesmes, Michael and humanitarian program led by Dorr, Peter Bex, Amy Kalia and Pawan Sinha. Massachusetts Institute of Technology Questioning professor, Pawan Sinha. The humanitarian no changes in their contrast sensitivity component of Project Prakash is cataract functions. The post-surgical visual the “Critical surgery, free of cost to children across assessments of contrast-sensitivity were India, to avoid preventable blindness. made in the field using an iPad-based Period” The scientific part (2) was to determine if assessment, rather than with the usual children who have suffered from extended cumbersome lab-based equipment. Received wisdom says that there congenital blindness – and were blind “With our test and some analytics we is a critical period after birth during the critical period – experience developed, we showed that some patients during which the brain is wired improvements in vision after cataract developed substantial vision after 15 years for sight; blindness then means surgery and, if so, how. They found that the of blindness,” says Bex (Figure 1). “This blindness for life. But a new human visual system does retain plasticity visual change could not be accounted for study challenges this wisdom by beyond the critical period. by simple optical factors.” demonstrating that congenitally “Our research group has been studying The paper’s authors concluded that blind children up to the age of 15 the development of vision in children their research “has important implications years can experience substantial who were blind from birth because of for potential treatments of congenital vision gains. congenital cataracts,” explains Peter cataracts, in addition to the fundamental Bex, a co-author and Senior Scientist at questions of development and plasticity In 1963, David Hubel and Torsten the Schepens Eye Research Institute, in neuroscience”. It would also suggest Wiesel, discovered that cats that had Harvard Medical School, Boston, USA. that it’s never too late to intervene to save one eye sewn shut from birth to three “We measured if and how their vision sight in children. months of age only developed full vision develops after surgery in late childhood in the open eye (1), and that monocular and adolescence to remove cataracts. Our References deprivation caused permanent results show remarkable plasticity; vision 1. T. Wiesel, D. Hubel, “Effects Of Visual electrophysiological and anatomical continues to improve in many children Deprivation On Morphology And Physiology changes in the cats’ brains. Sewing the long after the surgery.” Of Cells In The Cats Lateral Geniculate Body”, J eye closed after three months of age did Applying conventional wisdom, the Neurophysiol., 26, 978–93 (1963). not have this effect, so the immediate most conservative hypothesis for the 2. A. Kalia et al., “Development Of Pattern Vision postnatal three months was named the study would have been that children Following Early And Extended Blindness”, “critical period” for vision development. aged between 8 and 18 years would PNAS 2014 ; published ahead of print January In humans too, the greatest effects of show no changes in low-level vision, and 21, 2014, doi:10.1073/pnas.1311041111. 14 Upfront

Ranibizumab a Reality Bites

In the UK, real-world visual outcomes of patients receiving ranibizumab for neovascular AMD fail to match those achieved in most randomized trials. But they were delivered with substantially fewer injections and hospital visits.

Drugs almost always fare better in clinical trials than they do in the real world. Real-world patients do not comply as closely with b treatment regimens; they often have comorbidities that would see them excluded from a trial; and they have a tendency to miss appointments. In the UK, the real world has an additional confounding factor: a policy from the National Institute of Health and Clinical Excellence (NICE), which is the public body that advises on how drugs should be used. In the name of cost-saving, NICE advises that for the treatment of neovascular age-related macular degeneration (nAMD), ranibizumab should be administered far less Figure 1. The CATT research group (4) demonstrated that monthly administration, compared with frequently than the pivotal studies PRN ranibizumab dosing results in (a) reduced total macular thickness at the fovea and (b) greater that got the drug approved in the first improvements in visual acuity. place (2,3). The trials used monthly ranibizumab injections for two years; (but statistically significantly) worse than episodes on 12,951 eyes, over a period NICE advise that ranibizumab continuous monthly ranibizumab dosing of five years (5) to determine if the therapy be administered as a loading (Figure 1; 4). performance of inject-and-extend seen phase of three injections given at The UK also has an excellent in the trials exists in the real world. monthly intervals, followed by pro re central electronic medical records In comparison with the pivotal trials nata (PRN) treatment if active disease (EMR) system for ophthalmology. which used a monthly dosing regimen is detected at monthly assessment This enabled researchers from UK (2,3), the ‘inject-and-extend with visits. This so-called inject-and-extend Age-Related Macular Degeneration PRN’ approach resulted in lower visual protocol is based partly on the fact that EMR Users Group to perform a acuity (VA) gains, with vision tailing trials of monthly versus PRN dosing have multicenter, national nAMD database off after the peak gain, and a lesser shown that (under strict trial conditions) study on the records of 11,135 patients proportion of patients who gained at inject-and-extend therapy is only slightly that comprised 92,976 treatment least 15 letters of vision or maintained vision of 20/40 or better. The upside of the findings is that the vision gains that were achieved according to NICE’s recommended regimen were accomplished with fewer injections and hospital visits than in the pivotal studies. Looking at the data, the authors suggested that “the proportion of patients with VA of 20/40 or better will reflect not just the efficacy of the treatment but also how quickly patients can access the treatment,” and warned of the problems that “capacity constraints that prevent intended monthly review at some centers” can have on patients’ vision. One take-home message from this analysis seems to be: if you have a patient on PRN ranibizumab dosing, make sure that patient is seen monthly. MH Ophthalmologists • Second most likely to rate their health as Good or Excellent References are Healthy, (only dermatologists were thinner 1. National Institute of Health and Clinical or considered themselves healthier) Excellence TA155 Macular degeneration Wealthy and Wise • In the top quarter of those most (age-related) - Ranibizumab and Pegaptanib: likely to take over four weeks of Guidance. http://www.nice.org.uk/nicemedia/ Medscape assessed the vacation, coming in seventh live/12057/41719/41719.pdf. Accessed February lifestyles of physicians; of • The second highest amount of 3rd, 2014. the twenty-six specialties savings across all specialties (only 2. P. Rosenfeld et al., “MARINA Study Group. covered, ophthalmologists orthopods saved more) Ranibizumab For Neovascular Age-Related have the most to boast about. Macular Degeneration”, N Engl J Med., 355, More than 60 percent of 1419–31 (2006). Medscape’s recently-published ophthalmologists eat out at least once 3. D. Brown et al, “ANCHOR Study Group. annual Physician Lifestyle Report a week, half take vitamin supplements Ranibizumab versus verteporfin for neovascular comprises twenty-two slides that and over a quarter use complementary age-related macular degeneration”, N Engl J detail US physicians’ health, social life, or alternative therapies. Med., 355, 1432–44 (2006). financial situation, religious beliefs and Almost eight out of ten 4. CATT Research Group, “Ranibizumab and political views. Five intra-specialty ophthalmologists surveyed claim to bevacizumab for neovascular age-related macular charts reported on the body mass drink no alcohol or consume less than degeneration”, N Engl J Med., 364, 1897–908 indices, length of vacation, feelings of one alcoholic drink a week, and three (2011). happiness at home and at work, self- quarters said they “were religious and/ 5. Writing Committee for the UK Age-Related ratings of health, and savings among or spiritual.” MH Macular Degeneration EMR Users Group, “The twenty-six medical specialties. Neovascular Age-Related Macular Degeneration Ophthalmologists came out of the Reference Database: Multicenter Study of 92 976 survey rather well, being: Medscape Ophthalmologist Lifestyle Report 2014, Ranibizumab Injections: Report 1: Visual http://www.medscape.com/features/slideshow/ Acuity”, Ophthalmology, Epub ahead of print • The second least likely to lifestyle/2014/ophthalmology, accessed February (2014). doi: 10.1016/j.ophtha.2013.11.031. be overweight 3rd, 2014.

Feature 17

How to Build a World-Class Eye Institute

At the age of 39, I left a satisfying career in the United States to follow a dream of building a world-class eye institute in my native India. Here’s how the adventure has unfolded over the last 28 years, and some of what I learned along the way.

By Gullapalli Rao

or its variety and satisfaction, I’d like to stake a patients, more than half of whom have had services completely claim for having the best job in the world. free of cost, regardless of the complexity of the procedure (see There is simply no such thing as a ‘typical’ day Table 1 for more indicators of the impact of LVPEI). for me. Today, for example, kicked off with a In this article, I shall lay out the philosophy of LVPEI, major policy discussion with the senior management team the origins and development of the hospital system and Fof the LV Prasad Eye Institute (LVPEI). Later, I spent the potential applicability of the model to other cities and time with our scientists, listening to some exciting recent countries of the world. To do this accurately, I shall also research on genomics before turning attention to this article. provide a little information on my background and career Tomorrow, I may be immersed in mobilizing our resources, – I’ve had wonderful mentors and chance encounters with building bridges with other organizations, or forming munificent benefactors, and their part in the story deserves national and international collaborations. I am 68 years old, I to be recognized. My constant concern is the lack of uniform still love it and have no intention of retiring in the traditional standards in medical care and education in India. There are sense in the foreseeable future. pockets of excellence, including ours, but we need uniform LVPEI is a comprehensive eye health facility. At the main excellence across the country, and that is lacking and it will campus, located in Hyderabad, India, we offer full patient get us into a lot of trouble, if not corrected. care, sight enhancement and rehabilitation services, as well as pursuing cutting-edge research and providing training Origins for all levels of ophthalmic personnel. We also run high- Nineteen seventy-four was a significant year in my life: my impact rural eye health programs, including 100 primary, wife and I moved to the United States of America for my 11 secondary and three tertiary centers at various locations; fellowship training. I initially joined Jules Baum at Tufts these are mainly in the state of Andhra Pradesh, with a lesser University in Boston, then Jim Aquavella in the University presence in the neighboring states of Odisha and Karnataka. of Rochester, New York. It was the start of a dozen wonderful Our mission is to provide equitable and efficient eye care to years that influenced our entire lives. For my part, I not only everyone, across all sections of society. Since the hospital was matured as a professional – the medical opportunities I had established in 1987 we have provided care to over 17 million could not have been matched anywhere else – but also as a 18 Feature

“The vision was limited when I look back and compare to what has been done, but at the time it seemed to be outrageously ambitious.”

person. Jules and Jim turned me into a solid cornea specialist, teaching me the best practices for management of corneal problems; crucially, they also taught me the right approach to excellence in patient care. That period set the entire course for the rest of our lives, inspiring us to return to India to do the work that has, for the over quarter of a century, defined my career. Throughout, I have relied on the immense support, partnership and guidance of my wife, Pratibha. What we gradually realized was that there was an As a young medic I fancied pursuing cancer research, incredible amount of avoidable (preventable and treatable) but my destiny was to be an ophthalmologist, like my blindness occurring in India, particularly in rural areas. father. He had gently nudged me towards his specialty, LVPEI performed an epidemiological study in the mid- but looking back at my medical school years, I found it the nineties, and we discovered that over three-quarters most interesting anyway. Before the US experience, a huge of blindness in our home state of Andhra Pradesh was influence on my residency training in Delhi was Professor avoidable: the diseases – cataract, correctable refractive Agarwal; he instilled in me the right way to think about errors and infection – were treatable but people just weren’t and approach ophthalmology. receiving treatment. It was clear that our mission had to be Pratibha and I had always intended to return to India but expanded. Over the years we have opened primary, secondary, we started thinking seriously about it in 1982. We decided and tertiary centers, bringing eyecare to some of the remotest to fix a date and to hand in our notice, otherwise we might villages in the region. We now operate in 120 locations, 100 never have ended up returning. I gave my employers four of which are in remote rural villages. This makes me proud. years’ notice in 1982, telling them that we’d be leaving in I grew up in a small village, and the system we have created the second half of 1986. Because of the long notice period, today reaches people who live in such villages. They have the nobody took it seriously, but we were true to our word, and by best eye care that we can provide. October 1986, we were back in India. The planning and development of the institute was The vision was limited when I look back and compare informed by how other prestigious eye institutes operated. I to what has been done, but at the time it seemed to be visited many centers of excellence, in India and around the outrageously ambitious. I wanted to develop an academic eye world, making copious amounts of notes. But what I wanted center based on those I was working at in the USA. It would to replicate boiled down to two key aspects: equity – we insist have tertiary care, education and research components; the that all patients are treated equally – and excellence through only thing I added to that list that Western centers didn’t smooth, efficient systems. have was a rehabilitation center for the irreversibly blind as The reaction of the ophthalmology community in an integral part of the Institute (which has been a central India at the time was mixed. Some of those in the medical pillar of our activities ever since). The aim was to be truly establishment embraced the idea and were very encouraging comprehensive rather than a center that operated on a single and supportive; others, whether driven by skepticism or disease, like cataract, as was the tradition at the time in India. jealousy, did what they could to kill it. But overall, there Table 1. LVPEI by Numbers

• Direct service is provided to about 2,000 villages through secondary and primary care • Around 16,000 eye care professionals from India and abroad have been trained • 29 PhDs have been awarded and over 1,300 research papers published • Assistance has been provided to rehabilitate over 120,000 persons with irreversible blindness or low vision • More than 47,000 donor corneas have been harvested, nearly 25,000 of which have been transplanted to needy patients • Permanent infrastructure has been established in 18 of the 23 districts of Andhra Pradesh • Eye care programs have been upgraded in 18 states of India and 16 other countries The Vision 2020 Initiative

I was heavily involved with the “VISION 2020: The Right to Sight” initiative when I was President and CEO of the International Agency for the Prevention of Blindness (IAPB), between 2004 and 2008. Our target was a world in which no-one is needlessly blind, a world where those with unavoidable vision loss can achieve their full potential; our goal was to achieve this by the year 2020. The program has had many successes, all driven by cross-sector collaboration, which enables public, private and non-profit interests to work together. All avoidable causes of blindness will not be eliminated by 2020, so the challenge still remains. Having said that, we implemented a framework that has started deliver quality care to people across the world. It’s up to each country to move forward in implementing blindness prevention programs using that framework; in this way, the world can at last eliminate needless blindness and suffering. Feature 21

weren’t that many obstacles that needed to be overcome. Plans for the institute were progressing well, when “Could Western countries something serendipitous happened. A mutual friend in America, Ratnam Mullapudi, introduced me to Ramesh also benefit? Well, the Prasad, son of the veteran Indian film producer, LV Prasad. United States has a large The Prasads immediately believed in the project and their involvement dramatically accelerated its development. population of poor people They provided land that was in a better location than what we had at that time, and donated approximately whose health needs are US$1 million in funds that enabled us to build a 50,000 square feet hospital. The name of the institute recognizes chronically underserved.” Prasad’s noble act.

Running the Institute Having said this, funding is an issue that is always with us. Within five years the institute had earned a substantial Concerted effort and sound management mean that LVPEI reputation in India and had made some kind of impact on has no bank loans or budget deficits, yet more than half of all the global scene. The former made it far easier to mobilize of our patients are treated free of charge, and an even greater resources within India – before that we were depending mostly proportion in our secondary and primary centers. To achieve on funding external to India. We have had a significant influx this, we are very, very cost conscious about everything except of funding and support from within India in the last seven the needs of the patients – on that we never compromise. We or eight years, which has been a very welcome development. restrict all other expenses, and spend only what we earn. I am That’s partly due to the astonishing economic progress that no financial wizard. We use simple, transparent systems that the country has experienced in recent times. Of course, that I can understand and feel comfortable with. is not without its problems: there has been tremendous social That’s not to say that we’re not excited by technological upheaval and a sickening level of corruption that erodes the innovation: we are. However, we set a high bar for the country’s integrity. We don’t pay any bribes to anybody at any cost effectiveness that new developments provide and level, meaning that certain things, such as obtaining essential thoroughly evaluate new instruments and equipment permits, has become very slow. before introducing them in our centers. To provide a recent example, LVPEI decided against laser cataract surgery. Our experts believe that it offers no specific advantage over the current system of phacoemulsification and other methods of cataract surgery. Nevertheless, we continue to implement state-of-the–art procedures where appropriate, and we use most current technologies. We are also contributors to innovation in ophthalmology. The latest development, begun in October 2013, is a collaboration between LVPEI and the Camera Culture group at the Media Lab of Massachusetts Institute of Technology (MIT). Called the Srujana Centre for Innovation, the goal is to develop state-of-art technology to diagnose and provide efficient treatment for all kinds of blindness, including breakthroughs for those living in remote areas. I find this work truly exciting. We initiated the project with a one-week workshop attended by a hundred engineering students from across the country. It resulted in twenty-seven prototypes and work has commenced on translating all that potential 22 Feature

into something tangible. Already, a way of performing refractive tests on mobile phones has been developed (http:// web.media.mit.edu/~pamplona/NETRA/), and other applications are in the works, from a portable ERG machine to a new system for detecting ocular disease in newborns. One reason that LVPEI has developed into a successful center is that we have recruited the right people. This starts with getting the “right kind of people” – people with standards, people with values. We have never compromised on that. Indeed, many positions have been left unfilled, sometimes for years, until the right person is found. What are we looking for? The right background, including education and anything we can discern about the kind of work that they’ve performed previously. Integrity is absolutely essential. As noted earlier, corruption is abhorrent to me. In addition, our staff must fully share the commitment to provide the best of care to all patients, regardless of their circumstances. In the past, I did not hesitate to suspend privileges of a surgeon who was overheard telling a patient not to be difficult because he was “non-paying.” I used to ask senior doctors directly in the interview, “Are you one of the top five in your area in the country today?”, and to junior doctors I’d ask, “Do you promise me that you will become one in the next five years?” That’s the stand that we took. So really, my ethos can be encapsulated by the three E’s: Equity, Efficiency, and Excellence. Once we have the right staff in place, my role is to provide them with the tools that they need to be successful. Actually, benefit? Well, the United States has a large population I adjust my management approach to suit the situation. So, of poor people whose health needs are chronically some people have called me a dictator while others insist that underserved. I have had informal conversations with people I delegate too much. What I actually do is this: I hand over a from the US about the LVPEI model, but I don’t think that particular area of responsibility to what I believe is the right anybody is seriously implementing our approach at the person. If they run with it, and run with it well, then I don’t moment. The American system has all the ingredients in intervene again. But if it’s not going so well, I involve myself place, it would just be a matter of changing the menu to quite a bit, gently or not so gently, to get things right. offer different products. I believe that with 10 to 15 percent of their budget they could provide full care for poor inner- LVPEI to the world city and rural populations. Perhaps that’s something for the Today, LVPEI offers the whole gamut of ophthalmological future. For me, it would be wonderful to give something services, from the provision of contact lenses to medical back to the country that offered me so much. retinal services, and everything in between. We have In the meantime, there are so many exciting things thriving educational and research centers, and with the going on. The days of indulging in favorite pastimes – golf, Ramayamma International Eye Bank, we have the single reading and sleeping – are far off. But when I do eventually largest provider of corneal tissue for grafting in India. leave, I want LVPEI to be in a situation like it is today: Our methods of running both the LVPEI and our growing, innovating, financially sustainable, a world- outreach centers are being studied and imitated in many renowned center – and treating all, equally. And I hope the developing countries. Could Western countries also next person sitting in my chair will do better than me. What others say

Brien Holden, Professor at the University of New South Wales School of Optometry and Vision Science, and CEO of the Brien Holden Vision Institutes in Sydney, Australia, and Guangzhou, China. “When Nag went back to India to establish the LV Prasad Eye Institute we began working together and I made the first of my now 54 trips to India. He was determined to build a center of excellence that would research the best possible ways to advance the welfare of his people through delivery of vision care and blindness prevention.” “Three decades later, tens of millions in India and hundreds of millions around the world have been helped by his eye care delivery systems, the knowledge LVPEI has generated and the training of thousands of eye care professionals. On a global level, Nag has led a renaissance in evidence-based eye care and through his work with the International Agency for the Prevention of Blindness, WHO and the numerous partner NGOs and Institutes created a revolution in blindness prevention.”

Sreekanth Ravi, CEO and President of Tely Labs Incorporated, philanthropist and serial information technology entrepreneur. “My brother Sudhakar and I have worked with Nag Rao and the LVPEI for over ten years. We have been, and continue to be, very impressed with the work and the dedication of the team, especially the good doctor himself. Whether it involves cutting-edge stem cell research, or day-to-day eye exams and related procedures, the LVPEI has become an integral part of the community and is recognized as a global leader in research and new procedures. All of this emanates from the commitment and dedication of Nag and his team; we are very proud to be associated with them.”

Ashok Devineni, Chairman of Nava Bharat Ventures Limited, a multinational power, mineral and agribusiness conglomerate. “Our involvement with the LVPEI began 25 years ago, and our support, initially modest, has grown substantially since then. We have derived enormous satisfaction from the support we have given to some of their projects, as they have delivered far in excess of what we expected, in terms of quality, equity and efficiency of their eye care services.” “The projects that we helped fund – an eye bank, a tertiary eye hospital and a secondary eye care center in a rural area – have become so large and successful that our donations pale in significance. One change ushered in by the LVPEI was equality in patient care: every patient is treated with the same level of high quality care without exception, which contrasts with the ‘VIP’ culture that was commonly prevalent in India at the time of the hospital’s inception.” The Ophthalmologist 2/14

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Surgical Procedures Diagnosis New Drugs

32-33 Great Expectations Fuel IOL Inclinations Are advances in IOL and 26-28 phacoemulsification technology driving The Perfect Anterior Capsulorhexis demand for cataract surgery more than Why getting the right shape and medical need? right size generates optimal optical outcomes.

29-31 Don’t Fear The Posterior Capsule Why we need a rethink of the surgical approach to the barrier between the anterior and posterior lens segments. 26 In Practice

The Perfect Anterior Capsulorhexis

Getting the right shape and right size for optimal optical outcomes

By Johan Blanckaert

Creation of the anterior capsulorhexis is a key stage in cataract surgery, and producing a precise rhexis is of paramount importance. The most commonly used technique to achieve this during phacoemulsification is continuous curvilinear capsulorhexis (CCC). CCC was first popularized by Gimbel, Neuhann and others (1- 3) to make lens removal and IOL implantation in the capsular bag safer; it avoided the radial tears which occurred frequently in the can-opener capsulotomies that were performed at the time. We have come a long way in the intervening 25 years! The technique requires a skilled surgeon to pay careful attention during the procedure. Historically, it was termed “continuous curvilinear capsulorhexis,” because the opening created did not have to be exactly circular to have all of the desired Figure 1. From the cystotome needle to the Alcon LenSx SoftFit femtosecond laser patient interface qualities at the time – a time before the (Alcon/LenSx, Aliso Viejo, CA, USA), different surgical tools are required to master the continuous advent of premium and aspheric IOLs. curvilinear capsulorhexis. When viscoelastic use became routine in cataract surgery, the technique with a 360° overlapping capsular extending beyond the optic edge may evolved into a full-circle tear, facilitated edge prevents IOL tilt, myopic shift, lose these advantages” (11). Here’s how by capsular forceps designed by Peter optic decentration, and posterior and I perform CCCs today. Utrata (see figure 1). Today, obtaining anterior capsular opacification, partly a precise circular capsulorhexis pays due to a combination of the symmetric Today’s CCC big dividends, enabling the surgeon contractile forces of the capsular bag, Before commencing the rhexis, the to achieve even the most demanding and the shrinkwrap effect (4–10). surgeon must place enough viscoelastic of refractive results. A correctly sized, However, “eccentric or irregularly material (such as Viscoat) in the anterior and a well-centered capsulorhexis shaped capsulorhexis with a diameter chamber to counter the pressure of In Practice 27

Figure 3. The shear and tear principle of manual continuous curvilinear capsulorhexis. Adapted from (12). Area x remains stationary while area y is pulled to obtained the desired tear direction. All of the pulling force is concentrated at the point of tearing and is in the same direction as the tear.

the vitreous. This flattens the anterior lenticular capsule, preventing a forward push of the lens by vitreous pressure, which can result in a radial tear. The manual CCC can be centered with the help of Purkinje images. A number of instruments can assist in this critical step, such as the VERION image guided system (See Figure 2) and the CALLISTO eye (Carl Zeiss Meditech, Jena, Germany), which enable an image of the ideal capsulorhexis to be displayed in one ocular of the microscope. If the surgeon matches this ideal circle with the anterior capsulorhexis, a CCC is Figure 2. View of the eye during treatment through the Alcon Verion image guided system. formed around the visual axis. 28 In Practice

Many different instruments can said this, there are now alternative References be used to perform the CCC, with methods to performing a manual 1. T. Neuhann. “Theory and surgical technic of selection depending on the length of CCC: mechanical devices, such as the capsulorhexis”, Klin Monatsbl Augenheilkd., 190, the incision that the surgeon chooses to Fugo Plasma Blade (MediSURG, 542–545 (1987). make. For example, cystotome needles Norristown, PA, USA) and of course, 2. H.V. Gimbel, T. Neuhann. “Development, or Utrata forceps can be used to perform femtosecond lasers. Helpfully, advantages, and methods of the continuous the CCC and 23-gauge vitrectomy- femtosecond lasers can rapidly and circular capsulorhexis technique”, J Cataract style forceps used for microincisional reproducibly create perfectly circular Refract Surg., 16, 31–37 (1987). cataract surgery (MICS; Figure 1). rhexis patterns – and in difficult cases, 3. H.V. Gimbel, T .Neuhann. “Continuous The size of the rhexis really does I find such instruments to be invaluable. curvilinear capsulorhexis”, J Cataract Refract matter; ideally, there should be a small The rhexis is performed without Surg., 17, 110–111 (1991). overlap with the intraocular lens optic. opening the anterior segment, and the 4. G. Ravalico et al., “Capsulorhexis size and Tricks to assist in sizing the rhexis sizing and the position of the rhexis can posterior capsule opacification”, J Cataract Refract include: be controlled almost to perfection. Surg., 22, 98–103. (1996). CCC was developed as a way to try 5. U. Aykan, A.H. Bilge, K. Karadayi. “The effect of • Making a corneal impression by to avoid the can-opener technique’s capsulorhexis size on development of posterior pushing a ring caliper on the cornea risk of developing multiple adjoining capsule opacification: small (4.5 to 5.0 mm) – much like the centering of the tears during the procedure (these versus large (6.0 to 7.0 mm)”, Eur J Ophthalmol., radial keratotomy incisions around could extend to the equator, even 13, 541–545 (2003). the visual axis in the old days. The to the posterior capsule during 6. E.J. Hollick, D.J. Spalton, W.R. Meacock. marker does not need to be inked; lens removal and IOL placement). “The effect of capsulorhexis size on posterior the faint corneal impression is But it has additional benefits. The capsular opacification: one–year results of a usually enough. strength of the CCC opening made randomized prospective trial”, Am J Ophthalmol., • Introducing the ring caliper (of the phacoemulsification safer and, along 128, 271–279 (1999). rhexis size you wish to achieve) with suitable imaging techniques, 7. J. Ram et al., “Effect of in–the–bag intraocular into the anterior chamber and enabled accurate sizing and positioning lens fixation on the prevention of posterior capsule placing it around the visual axis. of the capsulorhexis—something that opacification”, J Cataract Refract Surg., 27, The cohesive viscoelastic gives is critical for the proper function of the 367–370 (2001). enough pressure to push the caliper newer generations of intraocular lenses. 8. D.F. Chang, et al., “Pearls for sizing the gently against the anterior capsule. The perfect CCC is now considered capsulorhexis”, Cataract & Refractive Surgery to be circular, sized to have a minimal Today Europe., 3, 40–44 (2008). In manual CCCs, it is essential that overlap over the intraocular lens optic, 9. K. Hayashi et al., “Anterior capsule contraction capsule tear direction is controlled and centralized onto the visual axis. and intraocular lens decentration and tilt after (Figure 3), as the overall direction The advent of the femtosecond lasers hydrogel lens implantation”, Br J Ophthalmol., of pulling forces on the capsule flap I use today means that this can all be 85, 1294–1297 (2001). can cause different tearing direction achieved in essentially 100 percent 10. K. Hayashi et al., “Anterior capsule contraction patterns. There are no shortcuts here; of cases. and intraocular lens dislocation in eyes with this is a skill that has to be mastered pseudo– exfoliation syndrome”, Br J Ophthalmol., to achieve the perfect CCC. When a Johann Blanckaert is the Director 82, 1429–1432 (1998). tear does begin in a peripheral or radial of the Eye & Refractive Center in 11. K. Kránitz et al., “Femtosecond laser capsulotomy direction, immediate action is needed. Iper, Belgium and a Consultant and manual continuous curvilinear capsulorhexis Usually, a viscoelastic cushion is placed Ophthalmologist at UZ Leuven. parameters and their effects on intraocular lens in the zone towards the tear extension. He is the current President of BBO- centration”, J Refract Surg., 27, 558–63 (2011). The surgeon must grasp the capsule UPBMO, the Belgian Professional 12. B.S. Seibel, “Phacodynamics: Mastering the Tools close to the tear and then pull to the Union of Medical Specialists in and Techniques of Phacoemulsification Surgery exact center of the eye to recover the Ophthalmology and Ocular Surgery. (Third Edition)” ISBN 1-55642-388-8, capsulorhexis – this works even if the (1998). tear propagated under the iris. Having In Practice 29

Don’t Fear the Posterior Capsule

Why we need a rethink of the surgical approach to the barrier between the anterior and posterior lens segments

By Marie-Jose Tassignon

Do we surgeons have an irrational fear of the posterior capsule of the lens? ©Rajesh Babu Structurally, the posterior capsule is Posterior capsule opacification in a child's eye following cataract surgery very simple: a clear, elastic, membrane- like collagen structure synthesized by postoperative issues (1). In the early Encouraged by my results with the lens epithelial cells to encapsulate stages of our careers, we were constantly children, I started to reassess how I the lens fibers. Functionally, however, reminded by our seniors to guard the deal with adults with straightforward it forms a crucial barrier between the capsule, and most of us can remember cataracts. The lens that I implant has anterior and posterior segments, both the stress and frustration of our first few a circular optic that is inserted into anatomically and physiologically. And accidental posterior capsular ruptures. the center of both the anterior and it’s that barrier function that has lead My view is that, while a healthy posterior capsulorhexes. Despite the us to believe that the posterior capsule respect for the posterior capsule is fact that it is regarded by some as being should be seen and not touched. This is essential to ensure safe surgery, there a difficult and dangerous twist on a not without reason: accidental tearing are occasions when a controlled standard technique, I view the PPCCC of the posterior capsule during cataract capsular tear can be safe – and even as an essential part of the surgery. surgery complicates lens removal, advantageous. One such case is in Although the additional surgical steps hampers the insertion of implant creating a primary posterior continuous need to be mastered, I have found that lenses and results in a higher rate of curvilinear capsulorhexis (PPCCC), – both in performing the technique a useful technique that eliminates the and in teaching it – it’s no more risk of posterior capsule opacification difficult or dangerous than standard At a Glance (PCO) that sometimes occurs after surgery, provided that the surgeon has • The posterior face of the lens capsule “standard” cataract surgery. As post- a careful, methodical technique and provides a barrier between anterior surgical PCO complication rates are understands the characteristics of the and posterior segments during high in children (2), my preference in BIL implantation technique. cataract surgery pediatric cataract cases is to implant a • Accidental rupture of the capsule causes lens as primary surgery, but to perform How to perform a PPCCC complications but planned posterior a PPCCC before I implant the lens. Over the years, having performed capsulorhexis is as safe as standard surgery In my experience, combining the countless PPCCCs, I have refined a • Primary posterior capsulorhexis is PPCCC with the bag-in-the-lens technique that is simple and has served recommended in pediatric (BIL) eradicates PCO. The “optic- me well both in adult and pediatric cataract surgery buttonholing” technique described by cataract surgery. First, an anterior • Some advanced lens techniques Gimbel (3) and later re-introduced by capsulorhexis is performed using a in adults also use primary Menapace works on a similar principle, ring caliper with an internal diameter posterior capsulorhexis albeit with some variations (4). of 4.5 mm (in children) or 5.0 mm (in 30 In Practice

1 2 3

4 5 6

7 8 9

Figure 1. Performing anterior capsulorhexis following the internal border of the ring caliper (black) in a child’s eye with white cataract. Figure 2. ACCC is clearly visible after phaco aspiration of the lens content. Figure 3. Separation of posterior capsule and anterior hyaloid is initiated by injecting OVD (Healon GV, AMO) through a tiny hole performed at the posterior capsule. This maneuver is also referred to as “filling Berger's space.” Figure 4. The Berger's space is considered sufficiently filled when the detachment of the posterior hyaloid is equal in size to the diameter of the ACCC. Note the enlargement of the initially tiny posterior capsule puncture. Figure 5. Performing a PPCCC of the same size as the ACCC. Figure 6. PPCCC is finalized. Figure 7. Engagement of both the anterior and posterior rhexes within the lens groove (left side is already in place). Figure 8. Sliding of the right side of the capsules within the lens groove. Figure 9. Final positioning of Bag-in-the-lens with proper insertion of both anterior and posterior capsules within the lens groove. Very stable BIL positioning. In Practice 31

adults; Figure 1). The cataract lens can stabilized against the anterior capsule PC tears (7). In the long-term follow- be removed per the surgeon’s preferred by injection of supplementary OVD. up of these patients, my team has found technique. Once the lens and cortex Both anterior and posterior capsules that the postoperative complications have been removed (Figure 2), I refill are then glided within the lens groove were the same as that of standard the anterior chamber with dispersive at the left side (Figure 7) by exerting cataract surgery (8). With this in ophthalmic viscoelastic device (OVD). very delicate pressure. Then the right mind, I advocate that all surgeons who I inject over the level of the iris, as anterior and posterior capsules are wish expand their surgical skills and this provides a pressure balance in glided within the lens groove (Figure techniques learn PPCCC. the anterior chamber, counteracting 8), resulting in stable implantation of pressure from the posterior chamber. It the BIL (Figure 9). Marie-Jose Tassignon is Chief also serves to flatten the capsule, giving There are, of course, problematic and Chair of the Department of the most predictable platform for a cases. In patients with weak zonular Ophthalmology at the University controlled posterior capsulorhexis. It is fibers, the lack of counter-traction Hospital Antwerp, Edegem, Belgium particularly important to fill over the makes the posterior rhexis less and University of Antwerp, level of the iris to ensure that none of predictable. Here, the insertion of Wilrijk, Belgium. the OVD enters the bag. Filling the a capsular tension ring after the bag would push the posterior capsule aspiration of the last zonular fibers References into a concave shape and makes can provide the necessary counter- 1. R.B. Vajpayee, et al., “Management of posterior performing the posterior rhexis more traction. I also recommend using a capsule tears”, Surv Ophthalmol., 45, 473–88 difficult and unpredictable. capsular tension ring in patients with (2001). I aspirate any residual cortical fibers myopia (axial lengths ≥ 26.0 mm); 2. A.R. Vasavada, et al., “Posterior capsule manually with a syringe mounted on a they typically have large capsules management in congenital cataract surgery”, J Helsinki cannula. The PPCCC begins that require additional stabilization. I Cataract Refract Surg., 37, 173–93 (2011). with a small puncture in the posterior recommend this step because myopic 3. H.V. Gimbel, T. Neuhann, “Development, capsule with a 30G or tuberculin patients are more prone to anterior advantages and methods of continuous circular needle. At this stage, I inject Healon vitreous schisis and have a very large capsulorhexis technique”, J Cataract Refract Surg., OVD through the small posterior Berger's space with little anterior 16:31–7 (1990). capsule defect into the posterior vitreous support. 4. R. Menapace, “Posterior capsulorhexis combined chamber, filling the Berger's space I have recently developed bean- with optic buttonholing, an alternative to s and pushing back the anterior hyaloid shaped rings that can be inserted in tandard in-the-bag implantation of sharpedged face (Figure 3). The OVD gathers and the capsular bag or positioned in the intraocular lenses? A critical analysis of 1000 forms a blister-shaped (slightly larger sulcus. The inner part of the ring adapts consecutive cases”, Graefes Arch Clin Exp than the existing anterior continuous perfectly well in the bag-in-the-lens Ophthalmol., 246, 787–801 (2008). curvilinear capsulorhexis [ACCC]), groove, and as a result stabilizes a 5. M.J. Tassignon, et al., “Bag-in-the-lens providing a cushion of protection capsular bag/ bag-in-the-lens complex intraocular lens implantation in the pediatric that prohibits vitreous prolapses from in the presence of loose zonules (6). eye”, J Cataract Refract Surg., 33, 611–7 (2007). occurring (Figure 4). I continue the I have been performing a PPCCC as 6. M.J. Tassignon, S.N. Dhubhghaill, “Bean-shaped posterior rhexis with a microforceps standard in the majority of my cataract ring segments for capsule stretching and (Ikeda Fr 2268, EyeTech), using surgeries over the last decade, and centration of bag-in-the-lens cataract surgery”, J the size of the anterior rhexis as a have found that (usually) no anterior Cataract Refract Surg., 40, 8–12 (2014). guide (Figures 5 and 6). For pediatric vitrectomy is required. In fact, when 7. V. De Groot, et al., “Lack of fluorophotometric cataracts (5), the technique is performed correctly, there is very little evidence of aqueous-vitreous barrier disruption modified: the initial capsular puncture disturbance of the anterior hyaloid after posterior capsulorhexis”, J Cataract Refract is performed as described above, but face, and the eye retains the diffusion Surg., 29, 2330–8 (2003). the OVD injection is performed with a properties across the vitreous and 8. A. Galand, F. van Cauwenberge, J. Moosavi, DORC 41 G needle (Figure 3). aqueous interface of an eye with an “Posterior capsulorhexis in adult eyes with intact The bag-in-the-lens is then injected intact posterior capsule – a situation and clear capsules”, J Cataract Refract Surg., into the anterior chamber and most unlike that seen with accidental 22, 458–61 (1996). 32 In Practice

of slow, gradual clouding is a revelation; is more to the rate increases than that. Great it improves peoples’ outlook on life, and For example, the Olmsted County data extends their life expectancy (1). clearly demonstrated that the increase Expectations The procedure is increasing in in the number of procedures was greater popularity in almost all developed than that expected for demographic Fuel IOL countries, to the point where it is now the reasons alone (4). most frequently performed surgery in the Another series, the Beaver Dam Inclinations world. In the UK, the National Health Eye Study (BDES), has shed more Service reported a 1.6-fold increase in light on the issue (5). This longitudinal Cataract surgery and IOL cataract surgeries between 1998 and 2009 population-based cohort study implantation have come a (2); Australia saw a 1.4-fold increase in recruited people aged 43–84 years long way since the 1990s, just five years – between 2000 and 2005 during 1987 and 1988, and followed and it appears that technical (3), and in one US study in Olmsted them up every five years. Four follow- innovations are stoking demand County, a 2.5-fold increase was recorded ups have now been performed and more than medical need. between 1990 and 2010 (4). the resulting analysis published in At one level this isn’t surprising. Ophthalmology (5). The investigators By Mark Hillen Developed countries have an performed ocular exams with lens increasingly aging population, so the photography and grading at baseline Cataract surgery followed by intraocular number of procedures performed and at follow-ups, enabling lens lens (IOL) implantation is popular is expected to increase for purely opacity to be assessed. They also took with patients – clear vision after years demographic reasons. However, there medical histories and measurements In Practice 33

of blood pressure, height and weight. Adjustments for age and gender were made, as both are known to be risk factors for lens opacities. Analysis of the data revealed that the incidence of lens extraction steepened over the four follow-up periods, from 1.8 percent in the interval between the first and second examination periods, to 11.7 percent in the latest study interval. When split by age (less than 65 years or 65 years and older), it is clear that procedure rates are increasing in both age groups (Figure 1). The increases in procedure rates were associated with better pre-procedural visual acuity at each time point – in essence, surgeons have gradually been reducing the visual Figure 1. Lens extraction incidence by age at the beginning of each five-year interval in the Beaver opacity threshold before intervening Dam Eye Study (5). with cataract surgery. Jay C. Erie’s editorial (6) that can now routinely, reliably and swiftly better outcomes – particularly refractive accompanied the article couched the remove opaque crystalline lenses, and ones – patients with incipient cataracts developments in terms of “demand eliminate postoperative spherical or are being cautiously advised to swap and supply”. The past twenty years astigmatic errors. their old crystalline lens for an IOL. have witnessed substantial advances Erie argues that ophthalmologists’ in cataract extraction techniques, with ability to “provide a new, innovative References ever-improving phacoemulsificationcataract surgery ‘supply’ has provided 1. C.S. Fong et al., “Correction of Visual methods and iterative improvements of better outcomes, improved quality of Impairment by Cataract Surgery and Improved IOLs that leave those from the 1990s life, and exceeded patient expectations, Survival in Older Persons: The Blue Mountains as dated as Paisley pattern ties and the consequently, and quite naturally this Eye Study Cohort”, Ophthalmology, 120, 1720–7 Sony Discman. Today, postsurgical has driven increased patient ‘demand’ (2013). complication rates are the lowest they’ve for our service,” and notes that the 2. HESonline. Main procedures ever been, and refractive outcomes impressive outcomes seen with surgical and interventions: 2000-2008. http:// are the best that they have ever been, intervention is driving demand for www.hesonline.nhs.uk/Ease/servlet/ thanks in part to the introduction of second-eye surgery – that the initial ContentServer?siteID=1937&categoryID=215 toric IOLs in the late 1990s. operation has “changed our patients’ (2009). The combination of technological perceptions of disability and visual 3. H.R. Taylor, T.V. Hien, J.E. Keefe, “Visual advancements mean that cataract/ functioning in the fellow eye.” acuity thresholds for cataract surgery and refractive surgeons deliver sharp, long- This much earlier opacity threshold changing Australian population”, Arch term vision enhancements to patients for surgical intervention seems to have Ophthalmol., 124, 1750–3 (2006). that were unimaginable at the start of arrived without much debate. Surgery 4. H.E. Gollogly et al.,“Increasing incidence of the BDES study. This may explain the is never taken lightly; all interventions cataract surgery: population-based study”, J recent spike in the incidence of cataract carry risk, and it’s the surgeon’s Cataract Refract Surg., 39, 1383–9 (2013). surgery observed in the youngest age determination of the risk-benefit 5. B.E.K. Klein et al., “Changing incidence of lens group (55–59 years) in the study; balance that determines whether the extraction over twenty years: the Beaver Dam outcomes today are now so good that operation proceeds. The risks of adverse Eye Study”, Ophthalmology, 121, 5–9 (2014). even patients with incipient cataracts events in cataract surgery and IOL 6. J.C. Erie, “Rising cataract surgery rates: demand will benefit from surgery. Surgeons implantation are low; combined with and supply”, Ophthalmology, 121, 2–4 (2014). Five x first prizes of flights, accommodation and Travel delegate fees for EntriesAward close March 31st AAO 2014

Case Studies will be judged by How do you identify & manage a panel of experts based on: long standing refractory DME? Initial Diagnosis of DME • How adequately the patient’s initial Share your knowledge and win a trip to DME was characterized • What characteristics changed to Chicago to attend AAO 2014 warrant an intervention

Long-term Management of DME With Diabetic Macular Edema (DME) increasing in prevalence, a major • What management strategies were question facing ophthalmologists today is how to manage insufficiently employed before and after the patient responsive, long-term cases. There are treatment options, but when should a was diagnosed patient be considered unresponsive? What diagnostic criteria provide useful • Characterization of the patient’s categorization of the patient population? What readouts of responsiveness response and subsequent lack of to therapy are most reliable? response to therapies To help stimulate discussion of best practice within the community, The Ophthalmologist is organizing a competition for Case Study reports Progression of DME that address DME management. • Considerations made – and The five leading entries will be published as part of a feature in the print treatment strategies employed – in edition The Ophthalmologist, and the authors will be invited to attend the the management of patients who 2014 Annual Meeting of the American Academy of Ophthalmology, to failed to sufficientlyespond r to be held in Chicago, October 18–21, as our guests. Flights, accommodation current therapies and delegate fees will be covered. • Criteria generated that might enable The ten best submissions will be published online at: easier or better diagnoses of www.theophthalmologist.com. subsequent patients as being Case reports should include relevant positive and negative findings insufficientlyesponsive r to from history, examination and investigation, and should include current therapies clinical photographs. • Recommendations for a physician The closing date for submission is March 31, 2014. treating a patient presenting with an Full information on how to submit your entry can be found at identical case www.theophthalmologist.com/travel-award Submit your Case Study today and help the ophthalmology community to Management of Side Effects identify and manage patients with DME. • Cerebro- or cardiovascular side effects • Cataract extraction Enter online at: • Assessment of patient for steroid- theophthalmologist.com/travel-award induced changes in intraocular pressure • Recommendations to ensure Sponsorship for these travel awards, including funding for travel, intravitreal steroids are used accommodation, and registration, is kindly provided by Alimera Sciences Limited. appropriately, safely and effectively NextGen

Research advances Experimental treatments Drug/device pipelines

36-37 Cataract Benchmarking We mine the cataract literature to look at who’s publishing what and where.

38-40 Inkjet Interventions Keith Martin envisages a future where you spray on healthy stem cells during retinal surgery. 36 NextGen

Cataract PubMed topic frequency (Top 25) Benchmarking

You can’t predict the future, 1200 but a lot can be learned by analyzing what happened in the past. Articles in MEDLINE By Mark Hillen are indexed by Medical 900 Subject Headings (MeSH) Massive strides have been made in topics, that describe the article’s surgical techniques and intraocular main topics. Here are the top 25 lens technology yet cataracts remain MeSHterms over the last five the leading cause of visual impairment years of the human cataract (especially in in developing countries). literature. 600 To generate some insight into the past and future of the field, we asked the following questions:

• Who has published the most? • Who has had the greatest impact? 300 • Who has published the most? • What are the big topics being discussed? • Is this knowledge available online?

To provide the answers to these questions, a literature analysis was 0 performed. PubMed, was searched Cornea Myopia for cataract* with results limited to Cataract Vitrectomy Risk Factors Young Adult Young Astigmatism Visual Acuity the last five years, in humans (for a Pseudophakia Vision Disorders clinical focus). The data was analyzed Crystalline Lens, Aged, 80 and over Aged, Refraction, Ocular Lenses, Intraocular Lenses, Follow-Up Studies Follow-Up Prospective Studies Phacoemulsication Treatment Outcome Treatment Intraocular PressureIntraocular Corneal Topography Corneal Cataract Extraction Cataract in Microsoft Excel 2013. Studies Retrospective Postoperative Complications Postoperative Lens Implantation, Intraocular Lens Implantation, Tomography, Optical Coherence Tomography,

Number of 2010 publications 2012 per year 1737 2011 2009 1726 1652 1436 Impact This chart represents the impact factor of each Average impact factor journal, multiplied by the number of publications in each of those journals, per author. 1 publication 1.904 citations 120

30 11 differentpeople 14 differentpeople 14 differentpeople 19 differentpeople 15 differentpeople 6 differentpeople 16 differentpeople

0 Li J Li Y Li Xu L Liu Y Liu Yao K Yao Alio JL Wang Y Wang Wang L Wang Wang JJ Wang Findl O Jonas JB Zhang X Werner L Werner Wong TY Wong Kohnen T Kohnen Mitchell P Mitchell Pinero DP Agarwal A Pesudovs K Pesudovs Mamalis N Trivedi RH Trivedi Praveen MR Ferrer-Blasco Vasavada AR Vasavada Lamoureux EL Montes-Mico R Montes-Mico

Publication type Availability, cost PubMed categorizes the publication type by various categories, Even now, in 2014, 6 percent of these articles were unavailable represented here. Clinical study represents clinical evaluations of online, and only 16 percent of the total had their full article text a drug, device or technique that were not clinical trials. available for free

Review Free full text Unavailable Clinical online Letter study 6% 15% 16% 26%

16%

25% 18% Case Clinical Full 78% reports trial text upon payment/subscription 38 NextGen

Inkjet Interventions a) Retinal Cell Printing Can you envisage a future in which deploying a tiny cell-spraying device during vitreoretinal surgery reverses 0µm 2µm 4µm 6µm 8µm 10µm 12µm 14µm 16µm 18µm years of retinal cell death? Keith Martin can.

22µm 30µm 38µm 46µm 54µm 62µm 70µm 78µm 86µm 94µm By Mark Hillen b) Glial Cell Printing When a man tells you that, in ten years’ time, he envisages treating retinal diseases with a tiny inkjet printer head, you begin to wonder if 0µm 2µm 4µm 6µm 8µm 10µm 12µm 14µm 16µm 18µm he’s been drinking strong coffee with too much gusto that morning. But if that man is Keith Martin, Professor of Ophthalmology at the University 22µm 30µm 38µm 46µm 54µm 62µm 70µm 78µm 86µm 94µm of Cambridge, you need to revisit that diagnosis. Martin has the only inkjet printer in the world that can print retinal Figure 1. Retinal Cell Printing. Image sequences of (a) retinal cells and (b) puriﬁed glial cells as they ganglion cells (RGCs) and glia, are ejected from the nozzle, labelled with image capture time (1). and deliver a live product. He and colleagues Barbara Lorber, Wen- to glaucoma, the possibility of Has this been done with CNS cell Kai Hsiao and Ian Hutchings replacing them with cultured cells that types before? recently published the method in function in situ is exciting. We spoke There are no reports in the literature Biofabrication (1), and it’s a story to Martin about it. of adult CNS cell printing being of happenstance, cross-pollination achieved successfully, so this is a first – of ideas, and just giving things a go. How did this project come about? we don’t know how many people have Conventional wisdom had it that the Barbara has been working in my lab tried and failed. cells of the rat central nervous system for a number of years, trying to get (CNS) are too fragile to be fired RGCs to regenerate but this particular How exactly was it done? down a piezoelectric printer head; project was pure opportunism. The technique that we’ve developed that printed glia wouldn’t function Basically, it stems from a conversation involves separating adult retinal cells to provide support and nutrition to with her husband, who works on inkjet and loading them into a specially built neurons, and that printed RGCs printing technology, on the overlap piezoelectric inkjet printing device. This wouldn’t grow neurites (which are between what we do and what he allows us to fire cells out of the print head essential to communicate with other does. It turned into a Friday afternoon (Figure 1) at about 30 mph, that’s about cells). Martin and colleagues did the experiment: they decided to see if the a thousand cells per second, and we can experiments anyway. And they worked. cells could survive the printing process. print them in precise patterns (Figure As loss of certain retinal cell types Much to everyone’s surprise, they did. 2). This potentially gives us a way to is characteristic of many eye diseases, So it started there. recreate adult neuronal structures using from age-related macular degeneration printing technology. Is the goal to produce a retina that you can implant into a patient to replace a damaged one? Well, that’s a long way off. There are a number of more immediate ways that this might be useful. For example, printing retinal pigment epithelial (RPE) cells or photoreceptors, cell types that are lost specifically in certain conditions. One could envisage using the printing technology to create an implant outside the eye and then inserting it. With further miniaturization, it may be possible to spray cells within the eye, as part of vitreoretinal surgery. That’s what we’re looking to do, but it is far too early to talk about achieving it.

Might the optimal combination be a retinal prosthesis sensor and appropriate printed cells around it? Yes. I think the biggest advances will come not from using one of these technologies alone, but by combining them, coming at the problem from different approaches. The interface between the electronic and the biological approaches is one such combination.

Ultimately do you plan to build a retina? If so, what’s the scaffold that you’ll build it on – glia? Do other cell types, like those of the vasculature need to be incorporated? We’re certainly looking at other cell types. Glial-neuronal interactions are obviously very important for the health of neurons – they can’t function in the long term without the support of glia. In terms of regeneration, the glial effect really promotes the axonal regeneration; we saw far better axon regeneration from the RGCs. We are a long way from being able to replicate the vasculature. But there are other ways of stimulating blood vessel growth. In degenerative diseases, Keith Martin and Barbara Lorber 40 NextGen

the blood supply is not so much of a problem. For ischemic conditions it might be, but we’re sticking to the neurons and glia just at the moment. a g m In a decade’s time, where do you think this technology will be? We’d like to be using this as part of the treatment for regenerating the retina – that’s our main goal. As I said, I don’t think that this is the whole solution but it b h n will help. We will look at manufacturing artificial neuronal tissue and also at repairing what’s already there.

Will it be in clinical trials in 10 years’ time? c i o Yes, that’s the timescale we’re looking at. In terms of printing RPEs and photoreceptors it might even be a bit quicker than that, as those are more straightforward cell types. We started in RGCs because my main d j p interest is in glaucoma – a crucial element in the pathophysiology of all forms of glaucoma is RGC death. However, people who have looked at the work are saying that it may well be more relevant to replacing RPE e k q and photoreceptors.

What about the cornea? Could you repair selectively damaged areas with inkjet cell technology? I think that’s perfectly possible, and it f l r may well be easier than the neuronal cell types. I’m not sure anyone has tried as yet. This is a very adaptable and modifiable technology and if fragile neurons can survive it, then I’m sure that corneal cells will.

References 1. B. Lorber et al., “Adult rat retinal ganglion Figure 2. Photomicrographs of βIII tubulin (a marker of retinal ganglion cells – red colour) and cells and glia can be printed by piezoelectric Vimentin+ (a marker of glia – green colour) in cell cultures from: control retinal cells (a),(d), printed inkjet printing”, Biofabrication, 6, 015001 retinal cells (b),(e) and control retinal cells plated at the same number as the printed retinal cells (c),(f ), [Epub ahead of print] (2013). either on their own (g)–(i) or with the retinal cells additionally having been plated on (j) control glia, (k) doi:10.1088/1758-5082/6/1/015001. printed glia or (l) control glia plated at the same number as the printed glia (1). Scale bar: 50 μm. We are ranking the 100 most influential people in ophthalmology

Who are the clinicians and researchers The Process with the biggest impact on our field? Which CEO has shown most integrity, • Nominations for The Ophthalmologist Power List leadership and creativity? And where are are welcome from individuals, groups or organizations • You may nominate up to five individuals by sending the role models and thought leaders that are an email to: [email protected] inspiring big changes in ophthalmology? • The persons nominated should (a) be involved in some aspect of ophthalmology and (b) be active in The Ophthalmologist Power List 2014 will survey their field at the time of nomination the achievements of the outstanding men and • The deadline for nominations is 7 March 2014 women across ophthalmology. In doing so, it will • The full list of nominations will be put to the expert celebrate their achievements and offer insight into panel of judges our speciality’s contribution to society as a whole. • Under the guidance of the Chair, the panel will The Power List will shine a light on the physicians, decide on the final list of 100. The panel’s decision is scientists, engineers and business leaders who are final and no correspondence regarding their shaping the world of ophthalmology today. deliberations or the final list will be entered into • The Ophthalmologist Power List 2014 will We invite you, our readers, to nominate the people be published in the April 2014 issue of The that you believe are having the greatest influence. Ophthalmologist, in print and online Your suggestions will be considered by our panel of judges who will select the Power List. The Judges: Three ophthalmologists, one analyst and two industry executives. Texere Publishing has expertise in science, technology and medicine publishing and marketing. Now you can tap into our expertise to meet your communication needs. We offer customized print, digital, audio and multimedia services that will enable you to engage with customers, colleagues/ employees, and the wider public. Use our skills to help you to achieve your business goals.

For more information contact Tracey Peers [email protected] Publishers of 01565 752883

Custom Publishing.indd 1 16/01/2014 15:29 Profession

Your career Your business Your life

44-46 Premium Practice Promotion How patient engagement and education helps you market your practice and your premium procedures.

47-49 Educational Excellence – For Patients Textbooks are so 20th Century. Here is what 3D electronic patient education systems can do. 44 Profession

surgery clinics, and for femtosecond can to get the optometrist and general Premium laser manufacturers. I love sharing my practitioner referrals? This should “wow” experience and helping surgeons represent a steady flow of patients Practice optimize their business. into your practice, but these may be patients you don’t see if you don’t Promotion They don’t teach business at med school make the time and effort to maintain Strategic business planning is a task good relationships with your fellow Realizing the full potential that many physicians are unprepared physicians and eyecare professionals. of your cataract/ refractive for. I have observed this time after time The next fundamental is how you practice starts with in the years I have spent working in and your practice present yourselves. marketing… but it doesn’t stop ophthalmology, helping cataract and Even things like basic telephone there. Patient engagement and refractive surgery practices promote etiquette counts: every telephone call education, before, during and their services. Ophthalmologists have left unanswered could represent a lost after the procedure is what spent a huge proportion of their life in customer… but promptly answered produces results – and referrals. academia: attending medical school, calls represent potentially your first devoting years of postgraduate training opportunity to sell your practice and By Laura Hobbs to become a qualified ophthalmologist, premium procedures. Use your telephone then working in eye hospitals as a resident hold music and marketing to educate I was introduced to the ophthalmic world physician. Business training isn’t a big patients about the advanced procedures over 10 years ago as a thrilled LASIK part of their lives throughout any of that you can offer – and any special patient who referred family and friends it, and they think like caregivers, not opportunities that may be in place. to the clinic where my “miracle” occurred. business people. When some eventually The moment a patient enters your I was highly myopic and rather fearful of set up their own private practices, dealing practice represents another key stage in the procedure, but decided to try LASIK with the realities of day-to-day business their decision to choose you over your to improve my poor vision and eliminate in a competitive landscape – on top of competitors. Ask yourself what kind of the inconvenience of glasses and contacts. all of their other duties – can be both experience does a patient – or prospective To say I was amazed with my outcomes daunting and stressful. As the UK-based patient – have when they first walk is an understatement. I could not contain ophthalmologist Sheraz Daya puts it, through the door? Clean and modern my exuberance and shared my LASIK “Establishing a practice is a considerable practice receptions, patient lounges story with just about anyone who would investment. Doctors are seldom educated and procedure rooms are an absolute listen. After referring LASIK to multiple on practice development and what it requirement if you want to convey an air friends and family members, I was offered takes to have the ‘edge’.” of professionalism that reassures patients a job at the practice where I was a patient; What follows is a distillation of what I that your practice is the one to choose since then, I have worked to promote do to make a practice work as profitably and worth paying a premium for. There’s and proselytize the technique in both and effectively as possible. a great advantage to the patient being in high-volume cataract and refractive physically in your practice: it provides an Market your practice as effectively opportunity to meet and greet the patient, as possible build rapport, and instill confidence that At a Glance You are operating in a market where your practice is the one for them. Also, this • How to influence the metrics to increase patients have plenty of choice over is an opportune time to present premium your inquiries who performs their LASIK or cataract procedures through in-house educational • To convert calls into consultations – surgery. The first place to start when materials and visual marketing aids, like simple things like professional telephone you begin marketing your practice is at brochures, posters, or iPad animations etiquette can make a huge difference home. Ask yourself a few key questions that illustrate the benefits of top-of- • Patient education converts (Box 1 - Marketing Your Practice: Take the-range procedure or the best IOLs. consultationsinto premium procedures an Internal Self Check," on page 46.) Frankly, you need to educate patients on but also improve word-of-mouth Getting the basics right counts. For the benefits of your services every chance referral rates example, are you doing everything you you get. Patient education isn’t merely Profession 45 46 Profession

Marketing Your Practice: Take an Internal Self Check

 Are you encouraging optometric and general practitioner referrals?  How would you describe your patient’s experience…five-star hotel, sterile hospital, or budget chain?  Do you educate patients on your services every chance you get?  Are you spotlighting your advanced procedures and offering seasonal advice to callers with “message on hold”? Figure 1. An example of a patient appreciation event, which increases your practice’s profile in your local community.  Do you utilize in-house patient education with visual marketing a euphemism for “selling” – it’s a crucial 1) and open days are great for promoting aids, for example brochures, part of the surgical process, improving the your practice, and increasing the likelihood posters, and iPad animations? patient’s experience during consultation, of word-of-mouth referrals from former the procedure, and managing their patients, but they also make great fodder  Do you recognize who is expectations afterwards; it pays to for local newspaper articles. It’s likely that important with grass roots remember that word of mouth is the there are only a few, overworked journalists activities, such as patient ultimate way to grow your practice. employed at your local newspaper, so send appreciation events? When a prospective patient leaves them press releases that have done most the practice, remember to send a follow of their work for them (decent copy, good  Do you send thank you notes to up letter or email soon afterwards. It’s photographs, a good headline). It makes patients to bolster relationships polite, it consolidates everything that their life easier, and greatly increases the and encourage referrals? they’ve seen, and it keeps your practice chances of your press release being turned in the forefront of the prospective into an article, letting their audience know  Do you send press releases patient’s mind. It might just make about your expertise. to the local media, making the the difference between them choosing However, if you really want to create journalist’s life easier and letting you… or a competitor! a big buzz in the community, you often the community know of have to invest in advertising. Some of your expertise? External Marketing Campaigns the traditional approaches we use in Seventy percent of consumers prefer to the US include radio spots, television  Are you creating corporate learn about a company through articles, commercials, and print adverts. You may partnerships offering employee not advertisements. You can reach want to create a campaign with a mix of discounts and vision checks at consumers by working with local media media types if you have the luxury of a health fairs? to promote yourself. Grass roots activities large budget. If not, you need to be very like patient appreciation events (Figure selective with your advertising plans. It’s Profession 47

a good idea to use a savvy agency who sell your practice. Always check your links best way to do this is with an animations will vet through the various timing and and offers on a routine basis to make sure shown on an iPad. Another opportunity placement options and perform due all content is reading and directing as it is to educate all individuals in your patient diligence on demographics and target should. Optimize your website for mobile lounge (otherwise known as a boring markets. The alternative is to do the devices… It is projected that this year “waiting room”) by streaming video onto a market research yourself. Radio can be mobile internet will overtake desktop TV or monitor to create further awareness. cost-effective and regularly provides internet usage, so make sure your website If you don’t want to experience the Spanish a consistently great reach – car drivers looks as good on an iPhone as it does on Inquisition on procedure costs and basic stuck in rush-hour traffic make a captive an iMac. Make both sites convenient for questions, enlist the help of a Surgical audience. A more expensive approach users to call you, get your address, and Coordinator. They can be responsible is TV – although costly, it may be ideally “Book an Appointment Online” for patient counseling, reviewing flexible worth the investment since it can reach – the ultimate patient convenience! Some financing options, rapport-building calls/ many thousands of viewers. In many people dislike the telephone or may notes sent to prospective patients, post households, you’ll find that the TV is handle personal to-dos in the evening or op patients and referring physicians. You on, the laptop or tablet is nearby and a on weekends. For the more experienced can quantify productivity by tracking staff mobile device is within reach, so it’s easy crowd, why not consider an app? Creating effectiveness, using these parameters: for viewers to turn to a device to get more one that repurposes web content can be information – so have a website, and use as inexpensive as $1,500. Last but not Enquiry to Consult Conversion its URL in all of your advertising. You least, establish a social media presence on (daily phone/emails/walk-ins that book a may have heard that print adverts are less Facebook, Twitter, and LinkedIn. Provide consult) _____% popular with the younger iPhone-toting relevant information and eye health tips. generations, but you might not have My experience dictates that you should Consult to Premium Conversion (did heard that print is still a go-to for those beware of posts or tweets with a sales-like they book a premium procedure?) aged sixty years and above. This gives you tone – it lessens your credibility. ______% an opportunity to customize that content, both in terms of what is advertised, and You’ve Captured Their Attention… Remember to track the referral sources how: use large type. Last but not least, Success! All of your hard work is paying of surgery patients; this helps you spot many ophthalmologists use transport off and patients are inquiring by phone trends, and allocate your marketing adverts and roadside signage to create and online. Remember your professional investment more effectively in the future. awareness of their practice and products; polish – from answering the telephone and it’s worth considering. The bottom within two rings to minimizing wait Conclusion line is that in all of your advertising; times and seeking feedback with patient The key points to remember are remember to have a concise call-to-action satisfaction surveys. If you offer premium that patients can choose from many and maintain your branding. procedures, you must educate patients cataract and refractive surgeons. Price is on these options. This could be as simple sometimes an issue, but they are going www.yourpractice.com as a comprehensive packet mailed in to choose an ophthalmologist that they You need a website. Absolutely. If you advance of a new patient consult; which have confidence in – they are, after all don’t already have one, get started on credentials the physician(s) and outlines trusting you with their most important it today. Sites like wix.com can build your advanced services. Alternatively or sense: their sight. This means that your professional-looking websites for in addition, your scheduling staff should entire practice needs to come across as relatively trivial amounts of money; so send the patient an email confirmation professional in all of your marketing, and long as it contains who and where you with links to your website and applicable even more so in the practice. are, and what you do, then that’s a good videos to watch at their leisure. start. Getting professionals involved is Laura Hobbs is a Practice Development a better idea in the long-term; plan for In Clinic and After the Procedure Specialist working in the US, UK blogs, patient testimonial videos, and With all premium services, it’s imperative and Europe and was a recent presenter relevant content for the next phase of the to pre-educate patients on the potential for the 2013 ESCRS Practice website – it will look professional and will to become less spectacle-dependent. The Development Program. 48 Profession

At a Glance • Patient education helps manage expectations and improve outcomes • 3D animations of ocular diseases and surgical procedures educate patients effectively • Today’s electronic systems are interactive, brand-able and customizable • Social media integration is built-in, giving performance metrics

Patient education is important for by providing an honest appraisal of the Educational four reasons. risks and benefits of the procedure. First, it improves outcomes. The This ties in to the third point: Excellence – patient who understands the procedure informed consent. Often, there are and what’s required of him or her before, multiple elective treatment options For Patients during and after surgery will adhere more for patients; they need to decide closely to the prescribed therapeutic which one is the best for them from an Electronic patient education protocols, improving their outcomes. informed position. systems look great, Second, it reduces fear of the Fourth, education manages offer flexibility in what’s procedure. Ocular surgery, with its hooks, expectations. Patients with unreasonable communicated and can be cannulae and phacoemulsification tips, presumptions of what a procedure will branded with your logo. can look terrifying, and it’s only a Google give them are inevitably going to be Goodbye textbooks! search away. This terror can be mitigated disappointed by the post-operative by educating the patient on what the optical reality. A patient with reasonable By Mark Hillen technique is for, how it is performed, and expectations of treatment success will most likely be pleased with the results – and may recommend your services to others via word-of-mouth, while a disgruntled patient will do the opposite. Given the importance of the topic, you should pay great attention to how you educate your patients. If you are still using an old ophthalmology textbook to explain procedures, then it is time to move to a better way. Most of your patients will have higher expectations than to have you leaf through a medical book: smartphones and tablets have transformed how everyone accesses information, irrespective of their age. The good news is that computerized patient education suites provide an excellent way to inform patients. They walk through the causes and nature of ocular diseases and the surgical Figure 1. Optimed’s EyeDraw (left) and Eyemaginations’ LUMA (right) iPad apps. interventions that will treat them using three-dimensional animation. These you feel require to be shown – so, for system actually monitors social media videos convey all of the information example, with cataract surgery, you may sharing, and can offer performance graphically but in a manner that’s play the videos on the development of metrics of the extent and impact of slightly detached from the actual, “wet” cataracts, what impact cataracts have patient’s social media sharing behavior, reality of eye surgery. In essence, the on vision, the various surgical options which is useful market insight that will patient is fully educated, but without (for example, using, or not using, inform how you market your practice. seeing any gore. a femtosecond laser system), how Eyemaginations’ ECHO offering can One option is to sit the patient in the intraocular lens (IOL) is placed, let practices send information – such front of a screen or hand them an iPad, conclusion of the surgery, and post- as new patient forms, pre-operative and play the video. These systems can surgical care notes. You can pause the instructions, and directions to the incorporate your branding and play a video, and annotate or draw on the office – prior to the visit, saving staff loop of videos in your waiting room, screen to facilitate discussion. And you time, or send content to patients post- which not only looks good, but can also can link to related content; a video that visit, reinforcing both their diagnosis alert patients to some of the premium explains and illustrates points raised by and the recommended treatment procedures on offer in your practice. your patients should be just a click or a options, which patients can then share But systems like Optimed’s tap away. What’s also useful is that you with family and friends via email or CAPTIV8 and EyeDraw or can email links to the patient. After you social media. Eyemaginations’ 3D-Eye and LUMA have watched videos with them, they If you haven’t already invested in an applications (Figure 1) are not just can review them at their leisure, better electronic, social-media connected repositories of 3D animations of ocular facilitating their learning. patient education system, now may diseases and surgical interventions. You Patients can share these videos be the time to do so. The benefits of can do far more with them, interacting too. As they are branded with your patient education are legion; the pitfalls with the patient and the content while practice’s logo and information, this of not doing so are many and well- the video is playing. The content is split means increased exposure for your documented. The fact that such systems into multiple sections that represent practice on social media platforms like can help market your practice and tell a typical ophthalmologist’s workflow. Facebook, Twitter and YouTube – at you how well it has done so is a useful You could choose only the sections that no further cost to you. The CAPTIV8 side-benefit. Turning Dreams into Reality

Sitting Down With Walter Wrobel, CEO/ President, and Reinhard Rubow, CFO, Retina Implant AG Sitting Down With 51

What is the goal of Retina Reinhard and I joined the company in of making blind people see. If you are Implant AG? 2004 and spent the first year visiting very wealthy and can help make this WW: We exist to develop a retinal VC companies across Europe. They dream a reality, what could be better implant (hence the name). We all listened to our business plans, and than that? performed the basic research. We they all decided it was too risky. In WW: Yes, I agree. Also, some of the applied for and were awarded the 2006, by which time we had already VC companies that were afraid of the patents. It is a big idea and we believe implanted a device into a patient, risk in 2005 are now ready to invest in that our company that can turn it into we were approached by a New York- the company. But today, we have to say, reality, and bring a device to market. based VC group. They were ready to “No thank you, it’s too late.” invest, but couldn’t arrange the funds RR: We recently achieved the CE How big is the problem that you’re quickly enough – we were very close mark and celebrated our 10th year as a tackling? What is your market? to bankruptcy. By chance, a wealthy company. When we met with the very WW: Approximately one person in German entrepreneur (who wishes to first investors, business angels who every four thousand carries the gene remain anonymous) happened to visit put up money in 2003 and 2004, they for retinitis pigmentosa (RP) and they Professor Eberhard Zrenner – our said, “We have not seen a return on our will all experience vision loss over their medical advisor and founder of the money, but if you want more money, lifetime. Not all of them will become company. The entrepreneur had a good please ask. This work is valuable and functionally blind, but we estimate friend with RP, and he asked Zrenner important to us, we are happy that we that about 15 percent of people with what he could do with his money. invested and would do it again.” RP will, eventually. That’s our market: Zrenner told him, “Well, there’s a the inclusion criterion for our device is nice German technology just about to How would each of you characterize no functional vision. be sold to the US because there is no your management styles? RR: For people in this position, it’s German investor.” Immediately, the RR: Our staff enjoy a lot of freedom. a very large problem, because they can entrepreneur said “I’m going to invest We manage by objectives. Everyone become blind. With our chip they can into that!” has written objectives, which are see again, and can recognize objects. reviewed yearly, and all employees And you received the money on the know the objectives of everyone else, Several German research institutes same day? including Walter and myself. This came together to form Retina WW: More or less; within four days, openness ensures that we all know Implant. How important was that the we had €7.5 million in the bank. We what each other is working on, and we breadth of input? signed a contract with the entrepreneur can find ways to help one another and WW: It has been crucial. The animal that was one-and-a-half pages long; cooperate. model data from the research the New York VC company’s contract WW: I’d describe it as something institutes were convincing; without ran to several hundred pages. similar to a sheepdog – generally them, neither Reinhard nor I would That individual remains our major letting people do what they are best at have joined the company, nor would shareholder – although we do have doing, but if they take a wrong turn I any investors. The clinical results from other shareholders with smaller run around and bark a little bit. the patients in the pilot study have investments. He has continued to fund RR: What’s also very important turned out to be almost identical to the us through several further rounds, and is that we have no hierarchies. All of results from the animal experiments he is prepared to continue funding the staff report to either Walter or so the basic data from the turn of until the break-even point is reached. myself. We sit down together every the millennium formed a very solid week for a company meeting, but we’re platform for what we do today. Could you do it again today? not there to solve problems, we’re just RR: Looking back to 2006, we were updating one another on progress in How easy has it been to get venture very lucky; however, if we started again development, in clinical engineering, capital (VC) to development today and met the same investors, they and so on. Everybody is informed, the company? would invest in us again. This is an everybody knows where we are; I think WW: That’s an interesting story. “ethical” investment – the old dream that’s crucial. Winter ESCRS presents Showcase

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Alcon The new CENTURION® Vision System is the only intelligent phaco technology that optimizes every moment of the cataract surgical procedure. The new system automatically and continuously adapts to changing conditions within the eye, provides greater anterior chamber stability during each step of the surgery, and places optimized energy technology at the surgeon’s fingertips through enhanced fluidic management and surgical precision.

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Oculus OCULUS Pentacam®: The best choice for cataract and refractive surgeons! Visit booth G 15 to get the latest news about the Pentacam® HR. Check out the newest Pentacam® software and also the revolutionary Keratograph 5M, the topographer with colour camera and the Corvis® ST which shows the visualization of dynamic corneal deformation.