APRIL 2014 # 07

Upfront In Practice NextGen Profession IL-18 stakes claim as an Strategies for What are the benchmarks for Making conferences a AMD therapy managing research in DME? family affair

14 36 –37 42 – 44 48 – 49 Ecknauer+Schioch ASW Breathtaking So easytooperate!DirectAccess Beautiful cases. 1200cutsanteriorvitrectomy. trolled corticalclean-up.HFcapsulotomyfordifficult That’s 1.6 to3.2mm,fast,safeandtheACalwaysstable. Any nucleusfrom softtohardest, anyincisionfrom Strong www.oertli-catarhex3.com highest volumeinanyset-upatcontrolled costs. Lets you enjoy most advanced surgery from low to For You Built-in compressor. Justplugto90-230V. glaucoma surgery. Fantastictoetipofflowcontrol. glaucomafunction,thefutureinterno ofcombined Truly portable, 5kg, fits ina pilot’s case.HFDSab Unique brings afriendlynoteinyourOR. Bright, easytoread display. Amarvelof design, without confusion.Programmable for20surgeons. easyPhaco ® . CortexMode TM forprecisely con- ® toanyfunction Ecknauer+Schioch ASW Breathtaking So easytooperate!DirectAccess Beautiful cases. 1200cutsanteriorvitrectomy. trolled corticalclean-up.HFcapsulotomyfordifficult That’s 1.6 to3.2mm,fast,safeandtheACalwaysstable. Any nucleusfrom softtohardest, anyincisionfrom Strong www.oertli-catarhex3.com highest volumeinanyset-upatcontrolled costs. Lets you enjoy most advanced surgery from low to For You Built-in compressor. Justplugto90-230V. glaucoma surgery. Fantastictoetipofflowcontrol. glaucomafunction,thefutureinterno ofcombined Truly portable, 5kg, fits ina pilot’s case.HFDSab Unique brings afriendlynoteinyourOR. Bright, easytoread display. Amarvelof design, without confusion.Programmable for20surgeons. easyPhaco ® . CortexMode TM forprecisely con- ® toanyfunction 20. CynthiaRoberts 19. Paul Mitchell 18. Roberto Bellucchi 17. Stanley Chang 16. Stanzel Boris 15. SusanneBinder 14. Foster Allen 13. Pyott David 12. Michael Mrochen 11. SeangMeiSaw 10. McGhee Charles Aung 9. Tin 8. Daniel Martin 7. Staurenghi Giovanni 6. Scott Alan 5. EberhardtZrenner 4. Jager Martine 3. George Spaeth 2. BillAylward 1. Carmen PuliafitoCarmen 72 60 46 1 73 47 2 61 28 74 3 48 62 29 4 75 63 49 40. Bradley Straatsma 39. Peng Khaw 38. Allingham R. Rand 37. EmilioCampo 36. Stamper Robert 35. Singh Kuldev 34. Paul Foster 33. Paul Sieving 32. Alfonso Eduardo 31.Ningli Wang 30. Peter Barry 29. TonyAdamis 28. Farhad Hafezi 27. 26. Abramson David 25. EGrant Robert 24. Garway-Heath David 23. Osher Robert 22. WeinrebRobert 21. Claude Burgoyne 5 30 Hannah Faal 76 6 31 50 64 7 87 77 65 8 88 32 Who’s on theCover? Who

51 78 9 33 66 10 89 52 34 11 60. CarolShields Hugh Taylor59. 58. Evan Gragoudas 57. Joan Miller 56. 55.George Waring 54. 53. Mark SHumayun 52. 51. Richard Abbott 50. Zhang Xiulan 49. Parke David 48. 47. Zinser Gerhard Sommer 46. Alfred 45. Daniel Palanker 44. EmilyChew 43. 42. Ritch Robert TsubotaKazuo 41. 79 35 12 67 Shigeru KinoshitaShigeru SeregardStefan Ursula Schmidt-Erfurth Sunil Shah 53 90 13 54 80 14 36 68 91 15 37 81 38 55 16 92 82 39 17 80. Paul Sternberg 79. Maguire Al TassignonMarie-José 78. 77. YannuzziLawrence 76. John Kanellopoulos 75. Ahmed Ike 74. Ioannis Pallikaris 73. Nussenblatt Robert 72. Njuits Rudy 71. Nag Rao Mark Tso70. 69. Hageman Greg 68. JeanBennett 67. TetsuyaYamamoto 66. PhillipRosenfeld 65. JamesFujimoto 64. RogerHitchings 63. Usha Chakravarthy 62. Oliver Findl Quigley 61. Harry 18 83 40 69 56 19 93 20 41 94 21 70 22 95 42 84 57 23 96 43 71 58 100. HarminderDua 99. John Marshall 98. Spivey Bruce 97. DanAlbert 96. Dohlman Claes 95. Jorge Alio 94. Frank Holz 93. Donald Tan92. 91. Agarwal Amar Seiler 90. Theo 89. Richard Lindstrom 88. Auffarth Gerd 87. Chang David 86. DennisLam 85. Renato Ambrosio 84. Neil Bressler 83.Abhay Vasavada 82. Paul Kaufman 81. JimMazzo 24 97 44 85 David HuangDavid 25 59 99 86 98 26 100 45 27 Contents

36

17

48

03 Online This Month Upfront

10 iPhone eye imaging 07 Editorial The Power of the List 12 The Vitreomacular Interface By Richard Gallagher Influences AMD Outcomes

13 Stats on stats 08 Contributors 14 Interleukin for a better wet AMD therapy On The Cover Feature 15 POAG Predisposition APRIL 2014 # 07 Power List pastiche of Sir Peter 17 The owerP List 2014

Upfront In Practice NextGen Profession IL-18 stakes claim as an Strategies for What are the benchmarks for Making conferences a AMD therapy managing glaucoma research in DME? family affair

14 36 –37 42 – 44 48 – 49 Blake’s “Sgt. Pepper’s Lonely So let us introduce to you Hearts Club Band” album cover The neo and only Theo Seiler (1967). And The Ophthalmologist’s Top 100 Band.

0414 TOP.indd 1 04/04/2014 15:49 ISSUE 07 - APRIL 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 - Tracey Nicholls [email protected]

Digital Content Manager - David Roberts 14 [email protected]

Editor, Custom Publishing - Iestyn Armstrong-Smith [email protected]

In Practice 50 Traffic and Administration Manger - Claire Lally 34 Selecting for Patient Success [email protected] The best diagnostic tools ensure the right procedures are selected for patients, improving outcomes Published by for refractive surgery. Texere Publishing Limited, Booths Hall, Booths Park, 36 Glaucoma Management Strategies Chelford Road, Knutsford, Cheshire, When eyedrops aren't the WA16 8GS, UK answer, surgical techniques General enquiries: and drainage devices are what Profession www.texerepublishing.com helps glaucoma patients. [email protected] 48 Quality Family Time at a Congress +44 (0) 1565 752883 Taking the whole family to [email protected] conference locations gives you a NextGen new perspective on the places you visit. Distribution: The Ophthalmologist distributes 42 Benchmarking DME 17,934 printed copies and 7,295 electronic copies to a targeted Analyzing the last five years of European list of industry the literature on diabetic macular Sitting Down With professionals. edema tells a story of what the ISSN 2051-4093 priorities are and who is making 50 Dan Myers, President and CEO the most contribution. of Alimera Sciences, Inc. Corneal response due to an air ® OCULUS Corvis ST pulse, 140 images in 31 ms.

13.282 ms

15.114 ms

17.175 ms

19.007 ms

21.068 ms

22.900 ms Highspeed Scheimpflug camera visualizes the 24.961 ms

future of diagnosis 28.854 ms

30.915 ms Please note: The availability of the products and features may differ in your country. Specifications and design are subject to change. Please contact your local distributor for details.

Highspeed Scheimpflug camera in combination with non-contact tonometer:

• Precise measurement of the IOP

• Precise measurement of corneal thickness

• Information on biomechanical response

• Screening for ectasia

www.oculus.de

The Ophthalmologist Corvis ST Produkt 210x266 e 03.14.indd 1 31.03.2014 13:00:40 Corneal response due to an air ® OCULUS Corvis ST pulse, 140 images in 31 ms. The Power of the List Editorial The Ophthalmologist Power List 2014 is this publication’s catalog of the 100 most influential people in today.

13.282 ms

hy generate a Top 100? Of the many reasons, 15.114 ms the chief one is to catalog and celebrate progress. I believe that most ophthalmologists would agree that these are among the best 17.175 ms of times for the profession; an age of wisdom rather than of Wfoolishness. Your accomplishments include: the development of new surgical techniques, drugs and ophthalmic devices; breakthroughs in the understanding of , pathology and epidemiology; 19.007 ms improvements (arguably) in health care administration and delivery, and the growth of an industry and infrastructure to meet the complex medical needs of patients. 21.068 ms This progress is driven by people, and those driving this progress deserve recognition. One great way of doing this is to highlight the achievements of ophthalmology’s most influential contributors. And that’s what the Power List is: a celebration, acknowledgement and offer 22.900 ms of gratitude to some of the major contributors to ophthalmology today. I don’t claim that this is definitively the top 100 people in Highspeed Scheimpflug ophthalmology. It’s a subjective list, initially compiled from our 24.961 ms readers’ contributions. If it has shocking omissions or inclusions – do camera visualizes the let us know and help us by submitting nominations next year. The list was developed in three stages. In stage 1, we invited readers to nominate people that they thought deserved recognition future of diagnosis 28.854 ms – only those nominated were considered. In stage 2, a jury of five noted ophthalmologists (who prefer to remain anonymous and were modest enough not to vote for themselves) selected their top 100

30.915 ms Please note: The availability of the products and features may differ in your country. Specifications and design are subject to change. Please contact your local distributor for details. from the slate of nominees: the results were consolidated into a list of 100 names. In stage 3, the jury ranked the list from 1 through 100; the average scores provided the final Power List. To resume the Dickens theme, the list does contain both the season of light and the season of darkness. One dazzling feature of the list is its geographical scope. Within the Top 20, ten countries are represented, and within the Top 100 as Highspeed Scheimpflug camera a whole, there are representatives of 21 countries. Ophthalmologists from Asia, Africa, North America, South America, Europe, and in combination with non-contact tonometer: Australia are included in the list. Who would have imagined that a list of 100 influential ophthalmologists would have been so broad? (For the • Precise measurement of the IOP record, the five judges came from five countries and three continents). A darker aspect is the gender ratio: the entire list has just 13 women, and all of the Top 20 are men. That’s a depressing statistic. • Precise measurement of corneal thickness To those who participated, our thanks. To those who feel aggrieved, let us know and aim for satisfaction in 2015: the list will • Information on biomechanical response be an annual event. And to those named in The Ophthalmologist Power List 2014, our congratulations. More power to you! • Screening for ectasia Richard Gallagher Editorial Director www.oculus.de

The Ophthalmologist Corvis ST Produkt 210x266 e 03.14.indd 1 31.03.2014 13:00:40 Contributors Innovation Alain Saad Alain Saad specializes in cornea, cataract and refractive surgery at the Rothschild Foundation in Paris. He is a proponent of Descemet membrane endothelial keratoplasty (DMEK) and is working to generalize the procedure for treatment of endothelial disease. Alain co-developed the SCORE analyzer for the pre-operative screening of corneas. He shares his strong interest in refining patient selection for refractive surgery page 34.

Nicole Kretz The mother of two young children and wife of a prominent ophthalmologist, Nicole Kretz is determined to make the most of family time. That means that the family travels en masse to ophthalmology conferences, providing memorable travel and learning experiences as well as family fun. Nicole shares her top tips on how to do it with panache on page 48.

Isabelle Leach Ophthalmology is changing. We believe the future of Isabelle Leach is a medical doctor by training and a science writer with over ophthalmology is single-use. twenty years of experience by choice. A francophone from childhood, Isabelle Advances in understanding. has managed to have a writing career in two languages, writing across medicine’s many disciplines. On page 12, Isabelle writes about how the configuration of the That’s the reason we Innovations in patient safety, vitreomacular interface impacts on the efficacy of anti-VEGF therapy. develop over one hundred technology and technique. single-use products each year Malosa work alongside for pioneering procedures surgeons from throughout the such as ReLEx, DSAEK & ophthalmic profession. Femto-Phaco. Yourselves The 2014 Ophthalmologist Power List would not exist without the input of our Developing instruments to So, whatever advances readers. It was your votes that decided who would, and wouldn’t be in the Power List. It’s a list from the community, for the community, and we thank everyone enable the procedures of the lie ahead, we remain at the who took the trouble to nominate a worthy candidate. See the results of your future. cutting edge. handiwork starting on page 17.

ASCRS – Boston Booth 205—207 SFO – Paris Booth N13 +44 (0) 870 3000 555 RCO – Birmingham Booth F www.malosa.com

ophthalmologist working.indd 2 11/03/2014 15:54 Innovation

Ophthalmology is changing. We believe the future of ophthalmology is single-use. Advances in understanding. That’s the reason we Innovations in patient safety, develop over one hundred technology and technique. single-use products each year Malosa work alongside for pioneering procedures surgeons from throughout the such as ReLEx, DSAEK & ophthalmic profession. Femto-Phaco.

Developing instruments to So, whatever advances enable the procedures of the lie ahead, we remain at the future. cutting edge.

ASCRS – Boston Booth 205—207 SFO – Paris Booth N13 +44 (0) 870 3000 555 RCO – Birmingham Booth F www.malosa.com

ophthalmologist working.indd 2 11/03/2014 15:54 10 Upfront

– and with it, inexpensive telemedicine. iPhone eye It just looks ugly! Upfront Industry can help here; for example, imaging Welch Allyn will let you pair its €540 PanOptic Ophthalmoscope with Reporting on the More money-saving a professional-looking €65 iPhone innovations in medicine combinations of smartphones adaptor. That’s fairly frugal but only if and snap-on adapters that you already have the ophthalmoscope – and surgery, the enable you to perform eye but certainly isn’t if you don’t. But now research policies and examinations on-the-go. there’s a middle way. personalities that shape Robert Chan and David Myung of Smartphones hold much promise for Stanford University have designed two ophthalmology practice. ophthalmology outside of the clinic. cheap, smartphone accessories, and Their cameras are continually improving published them in the March issue of We welcome suggestions in terms of sensor resolution, light the Journal of Mobile Technology in on anything that’s sensitivity, and lens quality. The LED Medicine. The first device can clip on to flashes provides a steady, illuminative any smartphone and consists of a macro impactful on light source, and the hefty processing lens with a 2.5 cm focal length, attached ophthalmology; power and high-resolution displays onto a clip, and a “properly positioned” please email and high-speed network connections LED light source that illuminates the onboard mean that images can be eye – and can be used as a substitute for [email protected] acquired, analyzed, annotated, stored and a slit lamp (2). It is easy to use: switch on, shared in minutes on the same device. All hold with both hands; gently touch the that’s needed is the right app (FiLMiC patient’s head with a couple of fingers Pro, as it allows on-the-fly focus and so that you can rest the phone on those exposure adjustment) and a €20, 20 D fingers (enabling you to hold the lens at lens held at the right distance (which can the correct distance to image the eye) and be tricky to master), and (discounting operate the touchscreen buttons with a the cost of the smartphone), you have an spare finger on the other hand. The team’s inexpensive ophthalmoscope (1) second device, developed in conjunction with Mark Blumenkranz, is a 3D-printed iPhone attachment that contains a mount for an indirect ophthalmoscopy condensing lens. The mount is positioned at a prescribed (but adjustable) distance from the iPhone’s camera lens, enabling focusing of the image onto the for fundus imaging. As before, FiLMiC Pro is being used as the image acquisition app. These devices were designed to be inexpensive, with production costs being approximately €65 at the moment. “It took some time to figure out how to mount the lens and lighting elements to the phone in an efficient yet effective way,” said Myung, who built the prototypes with inexpensive parts purchased almost exclusively online, including plastic caps, Upfront 11

A plastic spacers, LEDs, switches, universal mounts, macro lenses and even a handful of Lego blocks. The simplicity of the second device, however, allows it to be 3D-printed, which means that anyone with a 3D printer and enough plastic substrate can build their own. Such printers are popping up all over the world, from battlefield hospitals to aid agency centers in rural areas of developing countries. As the substrate is cheap powdered plastic, once the printer is in place, producing such instruments could be as simple as downloading the designs and pressing print. Perhaps we’ll all be printing inexpensive iPhone indirect ophthalmoscope adapters sometime soon. MH

References 1. L.J. Haddock, D.Y. Kim, S. Mukai, “Simple, Inexpensive Technique for High-Quality Smartphone Fundus Photography in Human B C and Animal Eyes”, J. Ophthalmol, Article ID 518479 (2013). doi: 10.1155/2013/518479. Figure 1. (a) Smartphone Clip-on device, being rested on the physician's fingers to take a photograph, 2. D. Myung et al., “Simple, Low-Cost Smartphone and images of (b) a nasal pingueculum, and (c) a nasal pterygium. Adapter for Rapid, High Quality Ocular Anterior Segment Imaging: A Photo Diary”, Figure 2. (a) The FiLMiC Pro app in use with the 3D-printed lens mount, and (b) a superior Journal MTM, 3, 2–8 (2014). doi:10.7309/ horseshoe retinal tear imaged through the device and lens. jmtm.3.1.4. 3. D. Myung et al., “3D Printed Smartphone A Indirect Lens Adapter for Rapid, High Quality Retinal Imaging”, Journal MTM, 3, 9–15 (2014). doi:10.7309/jmtm.3.1.3.

B 12 Upfront

Samuel K. Houston III presented data from a retrospective consecutive case series that included patients with (n=51) and without VMA (n=153) (4). He reported that the groups had similar visual acuity (which improved over the two-year study period) and similar central retinal thicknesses. Yet, he noted that more intensive treatment was necessary for patients with VMA. “The longest interval extension occurred in the non-VMA group and was statistically significant,”

Image: Sebastian Waldstein Image: Houston said, “The anatomic factors may contribute to individual treatment colleagues at the Mayo Clinic in responses and should be evaluated and The Rochester, MN, USA, performed a considered in treatment decisions for retrospective case series analysis of neovascular AMD.” Vitreomacular patients with AMD who received Comorbidities like VMID have intravitreal anti-VEGF injections distinct effects on how regularly patients Interface and who either did (n=32) or did not must be treated with . (n=146) have VMID (2). They found Few patients behave like the “average Influences that eyes with VMID had similar best patient” of clinical trials, arguing corrected visual acuity (BCVA) to that tailored anti-VEGF treatment AMD Outcomes VMID-free eyes, but that they required regimens for AMD is required. more anti-VEGF therapy to achieve it. Evidence is stacking up that Those findings were confirmed by References the configuration of the VMI Ulrike Mayer-Sponer and colleagues 1. S. Waldstein, “Predicting Anti-VEGF Treatment alters the functional and at the Vienna Reading Center in Outcomes”, The Ophthalmologist, 3, 26–28 anatomic efficacy of anti- Vienna, Austria, who performed a (2013). VEGF drugs. subanalysis of data from a phase III 2. A.E. Green-Simms et al., “Visual and anatomical clinical trial that enrolled treatment- outcomes of anti-vascular endothelial growth By Isabelle Leach naïve patients with subfoveal factor therapy in exudative age-related macular choroidal (3). degeneration and vitreomacular interface disease: While it is the undisputed gold The patients were randomized to vitreomacular adhesion and epiretinal standard for wet AMD treatment today, receive ranibizumab therapy either membrane” , Retina, 33, 1359–1364 (2013). doi: treatment outcomes with intravitreal every month or every three months. 10.1097/IAE.0b013e3182845d18. administration of anti-VEGF agents The team found that patients with 3. U. Mayr-Sponer et al., “Influence of the vary from patient to patient. Many VMID (in this case vitreomacular Vitreomacular Interface on Outcomes of comorbidities have been identified as adhesion and release of vitreomacular Ranibizumab Therapy in Neovascular Age- contributing to this variation (1). A new contact) had to have the intensive, related ”, Ophthalmology, addition to that list is the configuration monthly treatment regimen to gain 120, 2620–2629 (2013) doi: 10.1016/j. of the vitreomacular interface (VMI); the full benefit of ranibizumab; ophtha.2013.05.032. three different reports have concluded patients receiving quarterly dosing 4. S.K. Houston, “Vitreomacular interface affects that VMI disease (VMID) can have experienced significantly poorer anti-VEGF injection intervals for AMD”. Oral a clinically important effect on visual visual outcomes. presentation at the 66th Annual Wills Eye outcomes and need for retreatment. In March 2014, during the 66th Annual Conference, Philadelphia, Pennsylvania, Last year, Amy Green-Simms and Annual Wills Eye Conference, March 6–8th (2014). Upfront 13

depending on their statistical repertoire”. scientific discourse? Are the reviewers? Stats on stats With little or no statistical knowledge, Do ophthalmologists receive adequately a reader could interpret the statistical trained in statistical methods? An advanced level of statistical methods presented in two in every ten Adam Jacobs, statistician and director of knowledge is necessary (20.8 percent) articles. To understand the statistical consultancy firm, Dianthus to critically appraise most more than half (51.4 percent) of the Medical, has a different interpretation. ophthalmology literature. articles, familiarity with at least 15 different “The research is framing the question in the statistical methods is required, rising to 21 wrong way,” notes Jacobs. “I don’t think it’s How much statistical expertise is required different categories of statistical methods necessary for an ophthalmologist – or any to comprehend the ophthalmology to comprehend the content of 70.9 percent other clinician – to be an expert in a wide literature? To find out, a recently- of articles, and to 29 statistical methods variety of statistical techniques”, asking, published study (1) surveyed the statistical to comprehend fully over 90 percent of “surely it’s the job of the study author to techniques used in all articles published articles. When the authors looked at the ensure that tricky statistical techniques are in 2012 in Ophthalmology, the Am. J. subspecialties of ophthalmology, articles explained clearly so that non-experts can Ophthalmol., and Arch. Ophthalmol. that pertained to retina and glaucoma still understand what’s going on?” MH To get a handle on just how tended to use more complex analysis than understandable the literature is, the those from the corneal subspecialty. Reference authors “estimated the accumulated number The study raises some questions. Is the 1. R. Lisboa et al, “Use of Statistical Analyses in the and percentage of articles that a reader journals’ readership sufficiently statistically Ophthalmic Literature”, Ophthalmology, pii: S0161- would be expected to be able to interpret numerate to be able to fully participate in 6420(14)00046-3 (2014). Epub ahead of print.

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ADV_210X130_maia.indd 1 02/04/14 12.40 14 Upfront

Interleukin for a better wet AMD therapy

Subcutaneously-administrated IL-18 works well to reverse choroidal neovascularization (in mice).

Interleukin-18 (IL-18) is a peculiar protein. It is pro-inflammatory, produced by macrophages, and plays a large role in cell-mediated immunity. But researchers at Trinity College, Dublin, Ireland, have demonstrated that rather than damage the retina, IL-18 has the potential to stop choroidal neovascularization (CNV) in its tracks (1). They were led to this surprising discovery by their earlier research that had demonstrated (in mice) Doyle Sarah Image: that the absence of IL-18 resulted in Figure 1. Mouse retinal pigment epithelial cells swelling following the introduction of adeno- excessive CNV (2), prompting them to associated virus over-expressing the immature form of interleukin-18, pro-IL-18 (green). examine whether IL-18 administration could put the brakes on laser-induced in preventing the swelling that follows intravitreally-injected anti-VEGF CNV progression. The study’s first laser-induced CNV. Co-administration drugs today, helping to lighten their author, Sarah Doyle said that they “were of both an anti-VEGF agent and IL-18 ever-increasing workloads. initially concerned that IL-18 might acted to attenuate CNV development Campbell concluded “While it is still cause damage to the sensitive cells of the further than either agent alone. early days yet, the fact that IL-18 has retina, because it is typically linked to One great potential advantage that already been tested in human subjects and inflammation. But surprisingly, we found IL-18 has is that it can be administered has a good safety profile both systemically that low doses had no adverse effects intravitreally or subcutaneously – in mice and from an ophthalmology perspective, on the retina and yet still suppressed the drug worked just as effectively by it looks like a promising candidate as we abnormal blood vessel growth.” either route. Matthew Campbell said, move forward.” MH This was promising news, given “GlaxoSmithKline has already started that the chronic use of anti-VEGF examining subcutaneously-administered References agents risks the development of retinal IL-18 for the treatment of various types 1. S.L. Doyle et al., “IL-18 Attenuates pigment epithelium (RPE) atrophy. of cancers across some clinical trials, and Experimental Choroidal Neovascularization as Overexpression of an immature to date, this method of administration a Potential Therapy for Wet Age-Related (not fully processed) version of IL- appears to be well tolerated, and IL-18 Macular Degeneration”, Science Translational 18 – pro-IL-18 – also resulted in appears to have a good safety profile.” Medicine, 6, 230ra44 (2014). Epub ahead of print. the same pathology (Figure 1), but If the study results are as applicable to 2. S.L. Doyle et al., “NLRP3 has a protective role in the administration of therapeutic mice as they are to humans, this could age-related macular degeneration through the concentrations of IL-18 (the final mean that ophthalmologists would induction of IL-18 by drusen components”, mature form) did not. Furthermore, IL- not necessarily have to administer Nat Med., 18, 791-798 (2012). doi: 10.1038/ 18 worked as well as anti-VEGF agents every IL-18 dose, as is the case with nm.2717. Upfront 15

POAG predisposition

Predictors for primary open-angle glaucoma in a South Indian population.

Applanation tonometry 6-year study 4316 subjects without Gonioscopy POAG Pachymetry 40 years of age and older Examination South Indian Optic disc evaluation population Automated perimetry

100 2500

80 2000

60 4316 1500 Subjects Male Female 40 without 1000 44.6% 55.4% Urban residence POAG risk predictors POAG X 20 100% 0 with 500 1.6 * POAG Baseline 0 Year 60

100 2500 100 80 70 80 2000 80 60 Each 10mmHg 50 60 4316 1500 60 increase in IOP Subjects Male Female No 40 Male Female X 40 without 1000 44.6% 55.4% 40 30 2.0 ** 50.4% 49.6% POAG POAG 20 20 100% 0 with 500 20 97.1% POAG POAG 2.9% 10 0 0 0 0 Myopia up 1.7

100 80 times and axial 70 X 80 length 1.5 60 50 per mm** Age60 related incidence (relative to the 40-49 year age group) No 40 * P=0.01 ** P=0.001 40 30 Male Female 50.4% 49.6% POAG 20 20 97.1% POAG 2.9% 10 0 0 Reference 2.3% 3.5% L. Vijaya et al. “Predictors for Incidence 0% 60-69* of Primary Open-Angle Glaucoma in a 40-49 50-59* years South Indian Population: The Chennai Eye years years Disease Incidence Study”, Ophthalmology, (2014). Epub ahead of print. TARGETING THE MEDIATORS OF INFLAMMATION1

IL-6 IL-8 VEGF ICAM-1 MCP-1

Delivering efficacy in the clinical setting2-5

These images are for illustrative purposes only and do not represent inflammatory mediator levels in the eye.

OZURDEX® (Dexamethasone 700 micrograms intravitreal implant in withdrawing the applicator from the eye, make sure that the actuator button is pregnancy unless the potential benefit justifies the potential risk to the foetus. applicator) fully pressed and has locked flush with the applicator surface. Remove the needle Lactation: Dexamethasone is excreted in breast milk. No effects on the child are in the same direction as used to enter the vitreous. Immediately after injecting anticipated due to the route of administration and the resulting systemic levels. Abbreviated Prescribing Information OZURDEX, use indirect ophthalmoscopy in the quadrant of injection to confirm However OZURDEX is not recommended during breast feeding unless clearly Presentation: Intravitreal implant in applicator. One implant contains successful implantation. Visualisation is possible in the large majority of cases. In necessary. Driving/Use of Machines: Patients may experience temporarily reduced 700 micrograms of dexamethasone. Disposable injection device, containing a cases in which the implant cannot be visualised, take a sterile cotton bud and lightly vision after receiving OZURDEX by intravitreal injection. They should not drive or rod-shaped implant which is not visible. The implant is approximately 0.46 mm in depress over the injection site to bring the implant into view. Following the use machines until this has resolved. Adverse Effects: RVO In clinical trials the diameter and 6 mm in length. Indications: Treatment of adult patients with intravitreal injection patients should continue to be treated with a broad spectrum most frequently reported adverse events were increased intraocular pressure (IOP) macular oedema following either Branch Retinal Vein Occlusion (BRVO) or Central antimicrobial. Contraindications: Hypersensitivity to the active substance or to (24.0%) and conjunctival haemorrhage (14.7%). Increased IOP with OZURDEX Retinal Vein Occlusion (CRVO). Treatment of adult patients with inflammation of any of the excipients. Active or suspected ocular or periocular infection including peaked at day 60 and returned to baseline levels by day 180. Elevations of IOP either the posterior segment of the eye presenting as non-infectious uveitis. Dosage and most viral diseases of the cornea and conjunctiva, including active epithelial herpes did not require treatment or were managed with the temporary use of topical Administration: Please refer to the Summary of Product Characteristics before simplex keratitis (dendritic keratitis), vaccinia, varicella, mycobacterial infections, IOP-lowering medicinal products. The following adverse events were reported: Very prescribing for full information. OZURDEX must be administered by a qualified and fungal diseases. Advanced glaucoma which cannot be adequately controlled common (≥1/10): IOP increased, conjunctival haemorrhage* Common (≥1/100 to ophthalmologist experienced in intravitreal injections. The recommended dose is by medicinal products alone. Aphakic eyes with rupture of the posterior lens capsule. <1/10): Ocular hypertension, vitreous detachment, cataract, subcapsular cataract, one OZURDEX implant to be administered intravitreally to the affected eye. Eyes with Anterior Chamber Intraocular Lens (ACIOL) and rupture of the posterior vitreous haemorrhage*, visual disturbance, vitreous opacities* (including vitreous Administration to both eyes concurrently is not recommended. Repeat doses should lens capsule. Warnings/Precautions: Intravitreous injections, including OZURDEX floaters), eye pain*, photopsia*, conjunctival oedema*, anterior chamber cell*, be considered when a patient experiences a response to treatment followed can be associated with endophthalmitis, intraocular inflammation, increased conjunctival hyperaemia*, headache Uncommon (≥1/1,000 to <1/100): Retinal subsequently by a loss in visual acuity and in the physician’s opinion may benefit intraocular pressure and retinal detachment. Proper aseptic injection techniques tear*, anterior chamber flare* Headache. Uveitis In clinical trials the most frequently from retreatment without being exposed to significant risk. Patients who experience must always be used. Patients should be monitored following the injection to permit reported adverse events in the study eye were conjunctival haemorrhage (30.3%), and retain improved vision should not be retreated. Patients who experience a early treatment if an infection or increased intraocular pressure occurs. Monitoring increased IOP (25.0%) and cataract (11.8%). The following adverse events were deterioration in vision, which is not slowed by OZURDEX, should not be retreated. may consist of a check for perfusion of the optic nerve head immediately after the reported: Very common: Increased IOP, cataract, conjunctival haemorrhage* There is only very limited information on repeat dosing intervals less than 6 months. injection, tonometry within 30 minutes following the injection, and biomicroscopy Common: Retinal detachment, Myodesopsia, vitreous opacities, blepharitis, sclera There is currently no experience of repeat administrations in posterior segment between two and seven days following the injection. Patients must be instructed hyperaemia*, visual impairment, abnormal sensation in the eye*, eyelid pruritis, non-infectious uveitis or beyond 2 implants in Retinal Vein Occlusion. Patients to report any symptoms suggestive of endophthalmitis or any of the above mentioned migraine. (*Adverse reactions considered to be related to the intravitreous injection should be monitored following the injection to permit early treatment if an infection events without delay. All patients with posterior capsule tear, e.g. those with a procedure rather than the dexamethasone implant). Please refer to Summary of or increased intraocular pressure occurs. Single-use intravitreal implant in applicator posterior lens, and/or those who have an iris defect (e.g. due to iridectomy) with Product Characteristics for full information on side effects. Basic NHS Price: £870 for intravitreal use only. The intravitreal injection procedure should be carried out or without a history of vitrectomy, are at risk of implant migration into the anterior (ex VAT) per pack containing 1 implant. Marketing Authorisation number: under controlled aseptic conditions which include the use of sterile gloves, a sterile chamber. Other than those patients contraindicated where OZURDEX should not EU/1/10/638/001 Marketing Authorisation Holder: Allergan Pharmaceuticals drape, and a sterile eyelid speculum (or equivalent). The patient should be instructed be used, OZURDEX should be used with caution and only following a careful risk Ireland, Castlebar Road, Westport, Co. Mayo, Ireland. Legal Category: POM. Date to self-administer broad spectrum antimicrobial drops daily for 3 days before and benefit assessment. These patients should be closely monitored for any signs of of Preparation: May 2013. after each injection. Before the injection, the periocular skin, eyelid and ocular implant migration. Corticosteroids should be used cautiously in patients with a surface should be disinfected and adequate local anaesthesia should be administered. history of ocular herpes simplex and not be used in active ocular herpes simplex. The Remove the foil pouch from the carton and examine for damage. In a sterile field, safety and efficacy of OZURDEX administered to both eyes concurrently have not Adverse events should be reported. open the foil pouch and gently place the applicator on a sterile tray. Carefully remove been studied and is not recommended. OZURDEX is not recommended in patients Reporting forms and information can be found the cap from the applicator. Once the foil pouch is opened the applicator should be with macular oedema secondary to RVO with significant retinal ischemia. OZURDEX at www.mhra.gov.uk/yellowcard. used immediately. Hold the applicator in one hand and pull the safety tab straight should be used with caution in patients taking anti-coagulant or anti-platelet off the applicator. Do not twist or flex the tab. With the bevel of the needle up away medicinal products. Interactions: No interaction studies have been performed. Adverse events should also be reported to from the sclera, advance the needle about 1 mm into the sclera then redirect toward Systemic absorption is minimal and no interactions are anticipated. Pregnancy: Allergan Ltd. [email protected] the centre of the eye into the vitreous cavity until the silicone sleeve is against the There are no adequate data from the use of intravitreally administered or 01628 494026. conjunctiva. Slowly press the actuator button until an audible click is noted. Before dexamethasone in pregnant women. OZURDEX is not recommended during

References: 1. Nehme A & Edelman J. Invest Ophthalmol Vis Sci. 2008;49(5):2030-2038. 2. Pommier S & Meyer F. Realites Ophthlamologuiques 2012; 195. 3. Augustin A. et al. Poster presented at EVER 2012, October 10-13; Nice, France. 4. Querques L. et al. Ophthalmol. 2013;229:21-25. 5. Rostron E. et al. Poster presented at North of England Ophthalmological Society (NEOS) Summer Meeting 2013, June 12; Chester, UK. Date of Preparation: March 2014 UK/0062/2014 TARGETING THE MEDIATORS OF INFLAMMATION1

IL-6 IL-8 VEGF ICAM-1 MCP-1

Delivering efficacy in the clinical setting2-5

These images are for illustrative purposes only and do not represent inflammatory mediator levels in the eye.

OZURDEX® (Dexamethasone 700 micrograms intravitreal implant in withdrawing the applicator from the eye, make sure that the actuator button is pregnancy unless the potential benefit justifies the potential risk to the foetus. applicator) fully pressed and has locked flush with the applicator surface. Remove the needle Lactation: Dexamethasone is excreted in breast milk. No effects on the child are in the same direction as used to enter the vitreous. Immediately after injecting anticipated due to the route of administration and the resulting systemic levels. Abbreviated Prescribing Information OZURDEX, use indirect ophthalmoscopy in the quadrant of injection to confirm However OZURDEX is not recommended during breast feeding unless clearly Presentation: Intravitreal implant in applicator. One implant contains successful implantation. Visualisation is possible in the large majority of cases. In necessary. Driving/Use of Machines: Patients may experience temporarily reduced 700 micrograms of dexamethasone. Disposable injection device, containing a cases in which the implant cannot be visualised, take a sterile cotton bud and lightly vision after receiving OZURDEX by intravitreal injection. They should not drive or rod-shaped implant which is not visible. The implant is approximately 0.46 mm in depress over the injection site to bring the implant into view. Following the use machines until this has resolved. Adverse Effects: RVO In clinical trials the diameter and 6 mm in length. Indications: Treatment of adult patients with intravitreal injection patients should continue to be treated with a broad spectrum most frequently reported adverse events were increased intraocular pressure (IOP) macular oedema following either Branch Retinal Vein Occlusion (BRVO) or Central antimicrobial. Contraindications: Hypersensitivity to the active substance or to (24.0%) and conjunctival haemorrhage (14.7%). Increased IOP with OZURDEX Retinal Vein Occlusion (CRVO). Treatment of adult patients with inflammation of any of the excipients. Active or suspected ocular or periocular infection including peaked at day 60 and returned to baseline levels by day 180. Elevations of IOP either the posterior segment of the eye presenting as non-infectious uveitis. Dosage and most viral diseases of the cornea and conjunctiva, including active epithelial herpes did not require treatment or were managed with the temporary use of topical Administration: Please refer to the Summary of Product Characteristics before simplex keratitis (dendritic keratitis), vaccinia, varicella, mycobacterial infections, IOP-lowering medicinal products. The following adverse events were reported: Very prescribing for full information. OZURDEX must be administered by a qualified and fungal diseases. Advanced glaucoma which cannot be adequately controlled common (≥1/10): IOP increased, conjunctival haemorrhage* Common (≥1/100 to ophthalmologist experienced in intravitreal injections. The recommended dose is by medicinal products alone. Aphakic eyes with rupture of the posterior lens capsule. <1/10): Ocular hypertension, vitreous detachment, cataract, subcapsular cataract, one OZURDEX implant to be administered intravitreally to the affected eye. Eyes with Anterior Chamber Intraocular Lens (ACIOL) and rupture of the posterior vitreous haemorrhage*, visual disturbance, vitreous opacities* (including vitreous Administration to both eyes concurrently is not recommended. Repeat doses should lens capsule. Warnings/Precautions: Intravitreous injections, including OZURDEX floaters), eye pain*, photopsia*, conjunctival oedema*, anterior chamber cell*, be considered when a patient experiences a response to treatment followed can be associated with endophthalmitis, intraocular inflammation, increased conjunctival hyperaemia*, headache Uncommon (≥1/1,000 to <1/100): Retinal subsequently by a loss in visual acuity and in the physician’s opinion may benefit intraocular pressure and retinal detachment. Proper aseptic injection techniques tear*, anterior chamber flare* Headache. Uveitis In clinical trials the most frequently from retreatment without being exposed to significant risk. Patients who experience must always be used. Patients should be monitored following the injection to permit reported adverse events in the study eye were conjunctival haemorrhage (30.3%), and retain improved vision should not be retreated. Patients who experience a early treatment if an infection or increased intraocular pressure occurs. Monitoring increased IOP (25.0%) and cataract (11.8%). The following adverse events were deterioration in vision, which is not slowed by OZURDEX, should not be retreated. may consist of a check for perfusion of the optic nerve head immediately after the reported: Very common: Increased IOP, cataract, conjunctival haemorrhage* There is only very limited information on repeat dosing intervals less than 6 months. injection, tonometry within 30 minutes following the injection, and biomicroscopy Common: Retinal detachment, Myodesopsia, vitreous opacities, blepharitis, sclera There is currently no experience of repeat administrations in posterior segment between two and seven days following the injection. Patients must be instructed hyperaemia*, visual impairment, abnormal sensation in the eye*, eyelid pruritis, non-infectious uveitis or beyond 2 implants in Retinal Vein Occlusion. Patients to report any symptoms suggestive of endophthalmitis or any of the above mentioned migraine. (*Adverse reactions considered to be related to the intravitreous injection should be monitored following the injection to permit early treatment if an infection events without delay. All patients with posterior capsule tear, e.g. those with a procedure rather than the dexamethasone implant). Please refer to Summary of or increased intraocular pressure occurs. Single-use intravitreal implant in applicator posterior lens, and/or those who have an iris defect (e.g. due to iridectomy) with Product Characteristics for full information on side effects. Basic NHS Price: £870 for intravitreal use only. The intravitreal injection procedure should be carried out or without a history of vitrectomy, are at risk of implant migration into the anterior (ex VAT) per pack containing 1 implant. Marketing Authorisation number: under controlled aseptic conditions which include the use of sterile gloves, a sterile chamber. Other than those patients contraindicated where OZURDEX should not EU/1/10/638/001 Marketing Authorisation Holder: Allergan Pharmaceuticals drape, and a sterile eyelid speculum (or equivalent). The patient should be instructed be used, OZURDEX should be used with caution and only following a careful risk Ireland, Castlebar Road, Westport, Co. Mayo, Ireland. Legal Category: POM. Date to self-administer broad spectrum antimicrobial drops daily for 3 days before and benefit assessment. These patients should be closely monitored for any signs of of Preparation: May 2013. after each injection. Before the injection, the periocular skin, eyelid and ocular implant migration. Corticosteroids should be used cautiously in patients with a surface should be disinfected and adequate local anaesthesia should be administered. history of ocular herpes simplex and not be used in active ocular herpes simplex. The Remove the foil pouch from the carton and examine for damage. In a sterile field, safety and efficacy of OZURDEX administered to both eyes concurrently have not Adverse events should be reported. open the foil pouch and gently place the applicator on a sterile tray. Carefully remove been studied and is not recommended. OZURDEX is not recommended in patients Reporting forms and information can be found Who are the 100 most influential people in ophthalmology? the cap from the applicator. Once the foil pouch is opened the applicator should be with macular oedema secondary to RVO with significant retinal ischemia. OZURDEX at www.mhra.gov.uk/yellowcard. used immediately. Hold the applicator in one hand and pull the safety tab straight should be used with caution in patients taking anti-coagulant or anti-platelet That’s the question we posed to ourselves – and then to you – over off the applicator. Do not twist or flex the tab. With the bevel of the needle up away medicinal products. Interactions: No interaction studies have been performed. Adverse events should also be reported to from the sclera, advance the needle about 1 mm into the sclera then redirect toward Systemic absorption is minimal and no interactions are anticipated. Pregnancy: Allergan Ltd. [email protected] the centre of the eye into the vitreous cavity until the silicone sleeve is against the There are no adequate data from the use of intravitreally administered or 01628 494026. two months ago, ahead of open nominations and a painstaking conjunctiva. Slowly press the actuator button until an audible click is noted. Before dexamethasone in pregnant women. OZURDEX is not recommended during judging process. Here, without further ado, we celebrate the answer. References: 1. Nehme A & Edelman J. Invest Ophthalmol Vis Sci. 2008;49(5):2030-2038. 2. Pommier S & Meyer F. Realites Ophthlamologuiques 2012; 195. 3. Augustin A. et al. Poster presented at EVER 2012, October 10-13; Nice, France. 4. Querques L. et al. Ophthalmol. 2013;229:21-25. 5. Rostron E. et al. Poster presented at North of England Ophthalmological Society (NEOS) Summer Meeting 2013, June 12; Chester, UK. Date of Preparation: March 2014 UK/0062/2014 18 Feature

(in100-21 alphabetical order)

Richard Abbott David Abramson Anthony Adamis

A former AAO President and David Abramson’s treatments for Anthony Adamis has had two recipient of the AAO Lifetime retinoblastoma have been adopted careers in ophthalmology: as Achievement Award in 2006, worldwide. These include the delivery a clinician and as an industry Richard Abbott specializes in of chemotherapeutics around the executive. One of the discoverers corneal and external diseases. He eye to prevent systemic toxicity of of the role that VEGF plays in currently chairs the AAO Task intravenous medication and the use retinal and leakage, Force for LASIK Quality of Life of high concentration - but low dose Adamis also participated in Outcomes and is the principal - chemotherapy delivered directly the development and launch of investigator of the proposed FDA into the eye via a catheter placed , the first anti-VEGF study researching LASIK in the groin, administered on an agent for use in ophthalmology. patient outcomes. outpatient basis.

Eduardo Alfonso Jorge Alió

Eduardo Alfonso is an A leading authority in the field of internationally known expert on refractive surgery, Jorge Alió is at ocular infectious diseases. In 2006, the forefront of much of research he documented an increase in the in the field. He is the medical incidence of an aggressive form of director of Vissum, Europe’s largest fungal corneal infection that was eye institute and research facility, related to soft contact lens use. His an ESCRS board member and findings drew considerable media founder of an eponymous blindness attention throughout the world and prevention foundation. significantly reduced the number of new infections.

Rand Allingham Tin Aung

Rand Allingham leads a large A clinician-scientist, Tin Aung NIH funded project that has the leads a glaucoma research group goal of identifying specific gene(s) in addition to his managerial responsible for glaucoma. He responsibilities. His research was previously responsible for an interests include angle closure investigation into cerebrospinal glaucoma and the molecular genetics fluid pressure as a glaucoma risk of eye diseases; he is also active in factor and he has an ongoing clinical research, having conducted interest in clinical management of studies on therapeutics, imaging, the disease. screening, clinical course and surgical outcomes of glaucoma. Feature 19

Bill Aylward Peter Barry Roberto Bellucci

Bill Aylward is a senior vitreoretnial Peter Barry has been an ESCRS Roberto Bellucci is the current surgeon who chairs the Informatics board member for more than 25 years, ESCRS President, and has a wealth and Audit Committee of the UK’s holding the position of treasurer, of experience in cataract, implant and Royal College of Ophthalmologists. and most recently, President. Barry refractive surgeries, having performed He is vice president of the Club led the ESCRS Endophthalmitis more than 20,000 procedures. Jules Gonin and was president of Study, which recommended the Bellucci has previously developed ESCRS from 2009-2011. Aylward adoption of intracameral cefuroxime surgical instruments to help with leads the development of the open- following cataract surgery with IOL IOL implantation and performed source, ophthalmology-tailored implantation – something that has important studies of pre-, peri- and OpenEyes electronic patient record saved thousands of eyes from post-procedural antibiotics and management system. potential blindness. topical anesthetics.

Susanne Binder Neil Bressler

Susanne Binder, a retina expert Neil Bressler’s main research interests whose principal interests are AMD are collaborative efforts in clinical trials and retinal surgery, has published of common retinal diseases, including over 200 original articles and is the age-related macular degeneration and editor of two books. She is considered . He is currently to be one of the great translators of chair of Submacular Surgery Trials, clinical research into clinical practice, DRCR.net, the Data and Safety and her work in stem cells has Monitoring Committee for the NEI’s recently drawn praise. intramural clinical trials and the FDA’s Ophthalmic Devices Panel.

Claude Burgoyne

An optic nerve head imaging legend, Claude Burgoyne currently investigates the effects of aging and experimental glaucoma on the load-bearing connective tissues of the optic nerve head within SD-OCT 3D histormophometric reconstructions. He also aims to model how an individual human optic nerve head will respond to a given level of IOP.

Jean Bennett Emilio Campos Usha Chakravarthy

Jean Bennett’s laboratory focuses on Emilio Campos’ research interests A retinal surgeon by training, the molecular genetics of inherited include strabismus and amblyopia. Usha Chakravarthy has been retinal degeneration, such as retinitis He is a co-author of the definitive involved in many of the major pigmentosa and AMD, with the textbook on strabismus, “Binocular international clinical trials, including objective of developing therapeutic Vision and Ocular Motility: Theory the IVAN, INTREPID, EUREYE, interventions. She used viral vectors and Management of Strabismus.” INDEYE, and V.I.S.I.O.N. studies, to deliver transgenes to specific Campos is former president of the as well as co-authoring Cochrane retinal cells, providing proof-of- Italian Ophthalmological Society, Review articles and guidelines for the principle for ocular gene therapy. and is currently a member of the Royal College of Ophthalmologists’ Her colleague and husband Albert board of directors of the International on the treatment of AMD. Maguire is also on the list. Council of Ophthalmology. 20 Feature

Stanley Chang Emily Chew

Stanley Chang is a specialist in Emily Chew is chair of the vitreoretinal disorders and surgery, AREDS2 study and participates whose techniques are used widely. He in the Actions to Control established perfluoropropane gas to Cardiovascular Risk in Diabetes prevent scar tissue proliferation on the trial. She is a medical retinal retina and applied perfluorocarbon specialist with extensive experience for flattening retinal detachment, in the design and implementation along with related techniques for of clinical trials across all phases. vitreoretinal surgery. With Avi Her principal research interests Grinblat, he developed a panoramic are diabetic- and age-related viewing system for retinal surgery. eye diseases.

Hannah Faal Napoleone Ferrara Oliver Findl

An eye-care program consultant to Napoleone Ferrara was involved With research interests in the field SightSavers International, Hannah in the isolation and cloning of of optical biometry, PCO and post- Faal is former president of the VEGF and demonstrated its role in surgical visual quality assessment, International Agency of Prevention angiogenesis. His work helped lead Oliver Findl is a prolific author, of Blindness and chaired the IAPB/ to the development of , having published over 200 peer- WHO Task Force for VISION 2020. and the clinical development reviewed articles in international She initiated the national eye care of ranibizumab. Today, his lab journals. He is an editorial board program in The Gambia and has investigates non-VEGF-related member of the Journal of Cataract helped to develop eye care policies angiogenesis mechanisms, which and Refractive Surgery and is the throughout West Africa. may lead to therapies effective in Secretary of the ESCRS. anti-VEGF non-responders.

Allen Foster Paul Foster

Allen Foster’s interests encompass Paul Foster published the first the control of blinding diseases; high-quality reports of glaucoma cost-effectiveness and quality of prevalence and risk factors in East life studies; the implementation of Asia, being the first to identify VISION 2020, and health service the large burden of angle-closure research for children and adults glaucoma cases in China. He also with disabilities. He is co-director pioneered population screening of the International Centre for and preventive laser surgery for Evidence in Disability and co- angle-closure glaucoma, performing director of the International Centre the first randomized trial of the for Eye Health. technique in rural Asia. Feature 21

James Fujimoto Greg Hageman Ted Garway-Heath

James Fujimoto’s primary research Over the past quarter-century, Research by Ted Garway-Heath focus is biomedical imaging Hageman has examined the genetics has provided many new tools. These with OCT and advanced laser and pathways involved in AMD, include the Moorfields Motion technologies. His research team was making major contributions to Displacement Test; The Moorfields responsible for the invention and the understanding of the disease. Regression Analysis, a software development of OCT, and today He has briefed the US Congress program for imaging performance in they push the boundaries of high- on the subject three times, started tomography; and the Garway-Heath speed and high-resolution imaging, two biotechnology companies and Map, used in research to establish the functional Doppler flow and served on numerous national and correlation between visual field and angiography as well as polarization international advisory boards, service optic nerve hypoplasia changes. sensitive methods. panels and review committees.

Evangelos Gragoudas

A world authority on the diagnosis and management of intraocular tumors, Evangelos Gragoudas' pioneered the use of proton beam irradiation therapy in the treatment of ocular melanoma. Along with Joan Miller (qv) and Anthony Adamis, Gragoudas was one of the first to describe the role of VEGF in pathologic retinal neovascularization.

Top 10 countries: 1 USA 51 2 UK 10 3 Germany 5 4= Austria 3 4= India 3 4= Italy 3 4= Japan 3 4= Singapore 3 4= Switzerland 3 9= Australia 2 9= China 2 9= Greece 2 9= The Netherlands 2

Mapping the locations of the Power List constituents 22 Feature

Roger Hitchings Robert Grant Farhad Hafezi

Roger Hitchings’ interests lie Robert Grant is CEO of Alphaeon, As a post-doc, Farhad Hafezi in optic nerve imaging, visual a “lifestyle healthcare” company, identified a gene that can completely field progression assessment, and has long been a key figure inhibit light-induced retinal damage glaucoma surgery and normal in technology and business in mice. Today his clinical focus is on tension glaucoma. He established development in the pharmaceutical, corneal and refractive laser surgery, the Clinical Trials Unit and the medical device, and healthcare and he is a pioneer of corneal collagen associated Reading Centre at markets. He was previously CEO cross-linking (CXL). Hafezi was Moorfields Hospital, with the latter and President of Bausch+Lomb instrumental in building IROC in being one of the UK’s key centers for Surgical and President of Allergan Zurich, where CXL technology evaluating outcomes in ophthalmic Medical, where he led the $3.2 billion underwent further clinical clinical trials. acquisition of Inamed. development.

Mark S Humayun

Mark Humayun is best known for his work on retinal implants. He participated in the first US clinical trial of the Argus II implant, placing it into the eyes of patients with end-stage retinitis pigmentosa. As a result, Argus II became the first retinal implant in the world to receive regulatory approval.

Martine Jager Paul Kaufman Peng Khaw

A past president of ARVO, Martine Paul Kaufman is a researcher Peng Khaw is a prominent glaucoma Jager’s research interests are in glaucoma, in particular the surgeon, having pioneered numerous immunology and the development mechanisms of aqueous humor techniques and anti-scarring of uveal melanoma and ocular formation and drainage, and regimens. His team’s research led surface disease. Following a PhD age-related loss of near vision. He the introduction of intraoperative in immunology at the University of previously served as President and antimetabolites, and he introduced Leiden, Jager was ophthalmology Executive Vice President of ARVO, the Moorfields Safer Surgery System, resident at the University of and is a former president of the dramatically reducing bleb-related Amsterdam and a clinical fellow at International Society for complications. Khaw was knighted in Miami’s Bascom Palmer Eye Research. the 2013 Queen’s Birthday Honors Eye Institute. list for services to ophthalmology.

Shigeru Kinoshita Dennis Lam Daniel Martin

Shigeru Kinoshita established, along Dennis Lam has research interests Daniel Martin was extensively with Richard Thoft, the concept of that span the entire eye. He has involved in the development of centripetal movement of corneal contributed to studies from the the ganciclovir implant (and later epithelium. This shed new light on the cornea to the retina, and from valganciclovir) for the treatment of importance of the limbal epithelium epidemiological trials to genetic CMV retinitis, leading the clinical and contributed to the development studies. Lam is the founder of trials that resulted in FDA approval of corneal stem cell theory. Kinoshita’s the Project Vision Charitable of both drugs. He also helped lead group recently established systems Foundation, a charity that aims to the CATT trial, which compared to transplant cultivated mucosal try to eliminate cataract blindness bevacizumab with ranibizumab for epithelial stem cells and cultivated in China. the treatment of wet AMD. corneal endothelium. Albert Maguire

A pioneer of retinal gene therapy, Albert Maguire led a trial that inserted the RPE65 gene into the retinal pigment epithelium to treat Leber congenital amaurosis. He is a colleague (and husband) of Jean Bennett (qv). Recognized regularly by “Best Doctors in America”, Maguire is also a noted educator.

Jim Mazzo

Jim Mazzo is chair and CEO of Versant portfolio company AcuFocus, which specializes in corneal inlays, and is Executive Chair at Neurotech Pharmaceuticals, which is pioneering encapsulated cell technology as a drug delivery platform for retinal degenerative diseases. He spent seven years as Chair, President and CEO of Advanced Medical Optics. 24 Feature

Charles McGhee Paul Mitchell Joan Miller

A senior ophthalmic surgeon, A retinal specialist, Paul Mitchell A pioneer of Charles McGhee is also Editor focuses on the management of using , which was the first of the Journal of Clinical and AMD, diabetic and other vascular pharmacotherapy for wet AMD, Experimental Ophthalmology. He retinopathies, and investigations into Joan Miller also helped to define the chairs the RANZCO special interest how the eye is affected by systemic importance of VEGF in intraocular group in cornea, contact lenses, disease. Mitchell received the vascular disease. Today she continues and cataract and refractive surgery 2004 Association of International to investigate the molecular and is one of the most experienced Glaucoma Societies award, and pathophysiology of vision loss and corneal surgeons in New Zealand, in 2007 he became trustee for the to develop improved therapies for having performed over 500 corneal Clinical & Epidemiologic Research retinal disease. transplantation procedures. section of ARVO.

Michael Mrochen Robert Osher Carmen Puliafito David Parke

Michael Mrochen is most recently Robert Osher, a cataract and One of the co-inventors of David Parke, Executive Vice known for his pioneering work on implant surgeon, has designed many OCT, Carmen Puliafito is a President and CEO of AAO, corneal collagen crosslinking, but this contemporary IOLs and surgical pioneer of bevacizumab use has been a prominent and tireless is not his first innovation. Mrochen’s instruments, and has developed in retinal disorders, and was worker for the organization for research with Theo Seiler (qv) led to numerous new surgical techniques. the first to describe the use of many years. His service on the board the development of both wavefront- Many of these have been captured semiconductor diode lasers for began in 2000, first as trustee-at- guided and wavefront-optimized in video, and Osher’s surgical videos retinal photocoagulation. Puliafito large and ultimately as president. LASIK, which has transformed have won over 25 first-prize honors was also one of the original basic Parke, practicing ophthalmologist outcomes, minimized errors and at congresses across the world, science research leaders in excimer with subspecialty focus in retina/ made LASIK a safer and more including three Grand Prizes at laser photoablation and optical vitreous, received the AAO’s Senior predictable procedure. ASCRS and ESCRS. breakdown and photodisruption. Achievement Award in 1998.

Daniel Palanker

With forty patents to his name, Daniel Palanker is a crucial innovator for ophthalmology. His research led to the development of the Pulsed Electron Avalanche Knife, the Pattern Scanning Laser Photocoagulator, the CATALYS precision laser system, and most recently, an OCT-guided femtosecond laser system for cataract surgery.

David Pyott

David Pyott is credited with turning Allergan from a small eyecare business to a leading global specialty pharmaceutical and medical device company. This progress was driven by Pyott principally through significant investment in research and development, increasing the company’s investment from under $100 million in 1998 to more than $1 billion in 2013. Feature 25

Nag Rao Harry Quigley Robert Ritch

Nag Rao founded, the L.V. Prasad A founding member of the American Robert Ritch has devoted his career to Eye Institute, in Hyderabad, India. A Glaucoma Society, former CEO of two things: understanding the etiology global centre of not just excellence in ARVO and former Editor-in-Chief and mechanisms of glaucoma, and eyecare, research and rehabilitation, IOVS, Harry Quigley’s research has innovation in the medical, laser, and but also philanthropy: half of all enabled earlier glaucoma diagnosis surgical treatment of glaucoma. Ritch patients pay nothing. Rao is a past and described the degree of optical has held senior positions in many President of the IAPB and devotes nerve damage that had occurred ophthalmology societies and has much of his time to the IAPB and before glaucoma is typically detected. trained over 130 clinical and research the Vision 2020 initiative. His current research interests include fellows, many of whom occupy gene and stem cell therapies. academic positions worldwide.

Cynthia Roberts

Cynthia Roberts trained as a biomedical engineer and today works as a cross-college bridge between Medicine and Engineering, with appointments in both camps. Roberts’ research interests include corneal and ocular biomechanics in cornea, refractive surgery and glaucoma; in vivo measurement of corneal biomechanics and ophthalmic imaging applications.

Philip Rosenfeld Ursula Schmidt-Erfurth

Philip Rosenfeld, a retina specialist Ursula Schmidt-Erfurth founded the with particular interest in the Vienna Study and Vienna Reading treatment and study of macular Centers, which respectively run clinical degeneration, has been instrumental trials and perform digital image analysis in the clinical evaluations and for such trials. In addition to leading introduction of AMD therapies. one of the largest European academic These include photodynamic institutions in ophthalmology, therapy, as well as the introduction Schmidt-Erfurth has a keen interest into ophthalmology of the in the development of novel diagnostic VEGF-inhibitors, bevacizumab techniques treatment strategies, and ranibizumab. including intravitreal pharmacotherapy.

Seang Mie Saw

The principal investigator of several important epidemiologic studies in Singapore, Mie’s studies have encompassed myopia, strabismus, amblyopia and refractive errors in children. Highlights include elucidating genes and environmental factors involved in myopia and pathologic myopia, a major concern in East Asia. 26 Feature

Sunil Shah Alan Scott Stefan Seregard

Sunil Shah, a cornea and cataract Alan Scott was first to apply tiny Stefan Seregard has devoted consultant, is an advisor to the doses of botulinum toxin type A toxin the bulk of his research career to UK National Institute for Health to treat ‘crossed eyes’ (strabismus) examining how eye melanomas arise and Care Excellence where he and ‘uncontrollable blinking’ and spread in the body. Currently, he represents the Royal College of (blepharospasm), confirming his is trying to identify new therapeutic Ophthalmologists. However, he is idea that weakening the muscles avenues for ocular melanoma, and to most well-known as the inventor that pull crossed eyes inward would more clearly define the impact that of laser epithelial keratomileusis be an effective treatment. Allergan current therapeutic interventions (LASEK) in 1996, and continues to bought the rights to the drug and have on patients’ quality of life. be an active cornea researcher today. received FDA approval in 1989; it was renamed Botox.

Carol Shields

Carol Shields is an ocular oncologist. The oncology service that she runs with her husband Jerry and their associates manages 500 patients with uveal melanoma, 120 with retinoblastoma and numerous other intraocular, orbital and adnexal tumors, every year. In 2011 Shields was the recipient of the AAO’s Life Achievement Honor Award.

Kuldev Singh Paul Sieving

Kuldev Singh’s research interests Paul Sieving was the founder of the include glaucoma and cataract surgical Center for Retinal and Macular trials, epidemiology, genetics and Degenerations at the University Countries where most health care delivery in underserved of Michigan, and spent almost communities. His clinical practice sixteen years in Ann Arbor, before votes were cast focuses on medical, laser and surgical moving to Bethesda, MD, to become management of glaucoma and the Director of the National Eye cataract. Singh is president of the Institute, a position that he 1 Germany American Glaucoma Society and an holds today. advisor to the International Society of 2 Australia Glaucoma Surgery. 3 USA 4 China 5 Brazil 6 Italy 7 Nigeria 8 India 9= Japan 9= UK Feature 27

Alfred Sommer George Spaeth Robert Stamper Boris Stanzel

Alfred (Al) Sommer is responsible for George Spaeth discovered the Robert Stamper specializes in Boris Stanzel works on stem cell vitamin A supplementation, one of the disease homocystinuria and glaucoma and cataract surgery. replacement for frequent age-related most cost-effective health interventions. published much of the early work on His research interests include early blindness. With his collaborators, He demonstrated that vitamin A the condition, including the use of methods for the diagnosis of glaucoma Stanzel transplanted stem-cell- deficiency was far more common than pyridoxine as successful treatment. and the evaluation of new surgical derived retinal pigment epithelium previously recognized, and that even His surgical text is used in many procedures for glaucoma. He has into the subretinal space of rabbits, mild vitamin A deficiency dramatically countries and a fourth edition is published analyses of glaucoma a first in a large-eyed animal model. increases childhood mortality rates. currently being prepared. He was a eyedrops, implants and surgical The transplants remained intact at Dosing with vitamin A reduced child founding member and first president procedures. Stamper received an four weeks, suggesting that many of mortality and cut the incidence of of the American Glaucoma Society. AAO Lifetime Achievement Award the roadblocks to RPE monolayer measles-associated pediatric blindness. in 2008. transplantation have been overcome.

Giovanni Staurenghi Marie-José Tassignon

Giovanni Staurenghi’s principal With four patents that have interests are ocular imaging and been implemented in clinical the application of lasers to macular practice, Marie-José Tassignon is disease. His work extends to clinical a keen proponent of the need for trials and he is currently involved ophthalmologists to understand in more than 25 of them. A prolific physiology and the physics of optics. author on both eye anatomy and Tassignon developed the innovative disease, Staurenghi is a fellow of bag-in-the-lens implantation ARVO, AAO and EURETINA. technique that avoids PCO, the main complication of the traditional lens- in-the-bag implantation technique.

Paul Sternberg Bradley Straatsma

Paul Sternberg is a retinal specialist, Bradley Straatsma is widely acclaimed having been at the forefront of many as a pioneer in the study of peripheral advances in surgical techniques. retinal disease, investigations of He maintains an active academic tumors and research on ophthalmic and research program, studying the conditions such as diabetic pathogenesis of age-related macular retinopathy and cataract. Straatsma degeneration, and has played key was the last president of the American roles in many ophthalmology Academy of Ophthalmology and societies: in 2013, he served as the Otolaryngology, and led the formation President of the AAO. of the AAO.

Hugh Taylor Mark Tso Kazuo Tsubota

Hugh Taylor has a long and Mark Tso’s career has been built Kazuo Tsubota’s investigation and distinguished career in research on research in experimental and research interests include corneal into the causes and prevention of human ophthalmic pathology. regeneration, development of blindness in both developed and His studies on the benign form novel treatment modalities for developing countries, and has of retinoblastoma (fleurettes Sjögren’s syndrome and severe dry published extensively. His current in retinoma), pathology and eye. He also focuses on treating work focuses on Aboriginal eye pathogenesis of papilledema, macula age-related eye diseases such as health and the elimination of edema, retinal photic injury and macular degeneration, cataract and trachoma. Taylor is the Treasurer of photoreceptor degeneration have presbyopia. He has particular success the ICO and Vice President of been described as “innovative, treating near- and farsightedness as the IAPB. creative and original”. well as astigmatism. 28 Feature

George Waring III Ningli Wang Robert Weinreb Tetsuya Yamamoto

In the 1970s, George Waring While serving as director and the As a clinician, surgeon and scientist, Tetsuya Yamamoto has been established northern California’s vice president of one of the two Robert Weinreb maintains diverse part of many great advances in first eye bank. He subsequently largest eye centers in China, Ningli medical and research interests. knowledge in the field of glaucoma. moved to Emory University, Wang is also devoted to ophthalmic He is also a prolific educator; From population analyses of bleb where he is Clinical Professor of practice, teaching, training, many of his (more than 100) dysfunction, identification of genes Ophthalmology and, since 2003, blindness prevention and academic postdoctoral fellows in glaucoma associated with glaucoma, imaging he has practiced privately at the research. His contributions include have gone on to hold department studies and the use of antifibrosis InView Center, Atlanta. Waring the trans-lamina cribrosa chairs and other distinguished agents in glaucoma surgery, his has performed more than pressure difference theory of open- academic positions in the United contributions have significantly 10,000 LASIK and other angle glaucoma. States and throughout the world. advanced the field. refractive procedures.

Lawrence Yannuzzi

Lawrence Yannuzzi is a pioneer in angiography. He and his colleagues are credited with describing – and naming – idiopathic polypoidal choroidal vasculopathy, a type of hemorrhagic maculopathy. Yannuzzi has published more than 300 scientific papers and 11 textbooks, focused on diseases of the macula such as diabetic retinopathy and age- related macular degeneration.

Xiulan Zhang Gerhard Zinser Xiulan Zhang has a prolific publication record in glaucoma, The co-founder and a Managing having performed imaging studies Director of Heidelberg Engineering, that have furthered the understanding Gerhard Zinser has contributed of anatomical dysfunction in the to many key advances in imaging glaucomatous eye, and what surgical technology, including confocal interventions can do to improve microscopy, scanning lasers and matters. Zhang works at the optics, OCT and software image Zhongshan Ophthalmic Center, analysis. The resulting diagnostic which was voted China’s most popular instruments have changed clinical eye hospital for five consecutive years. practice for retinal disease, glaucoma and corneal pathologies.

Eberhart Zrenner

A graduate in electronic engineering as well as in medicine, Eberhart Zrenner’s career has merged his clinical and research interests. He founded the Institute for Ophthalmic Research where he runs a special clinic for patients with hereditary retinal degenerations. His research pursuits include retinal physiology and pathophysiology, ophthalmogenetics and retinal implants. Feature 29

The Top 20

20 Harminder Dua 19 Claes Dohlman 18 Robert Nussenblatt

An active clinician, teacher and Once referred to as “father of Robert Nussenblatt is an ocular prolific researcher, Harminder modern corneal science”, Swedish- immunologist. His primary research Dua’s most recent contribution born ophthalmologist Claes interests are uveitis and the role of to the science of ophthalmology Dohlman has spent the majority inflammation in causing AMD. He was the discovery of a new corneal of his career in Boston, becoming also investigates new therapeutic layer in 2013. He serves as editor- Chief of Ophthalmology the approaches to treating human in-chief of the British Journal of Massachusetts Eye and Ear disease, including oral tolerance Ophthalmology, is past president Infirmary in 1974. He developed the and the use of natural products, of EuCornea and is immediate past Boston keratoprosthesis, an effective and studies the role epigenetics president of the Royal College (and revolutionary) treatment plays in the development or non- of Ophthalmologists. option for severe corneal diseases. development of disease.

17 John Marshall 14 Bruce Spivey

John Marshall’s research covers Bruce Spivey is one of the great a wide range of ocular disorders educators in ophthalmology, and his research has covered the spending much of his career trying development of lasers for use in to improve how ophthalmology is ophthalmic diagnosis and surgery, taught and assessed. The current and it’s this that he is most famous President of the International Council for: he invented and patented the of Ophthalmology (and a former excimer laser and also created the AAO CEO), Spivey is the author first diode laser that was used for of over 130 scientific education and treating eye problems. management articles.

16 Gerd Auffarth 15 Frank Holz

Gerd Auffarth is director of the Frank Holz is an AMD researcher David J. Apple Laboratory. This whose focus is on the pathogenesis international lab, which is devoted to and therapy of AMD as well as on research on intraocular ophthalmic retinal imaging methodologies and devices, recently relocated to phenotyping. In addition, Holz Heidelberg from South Carolina. has lead numerous ranibizumab Auffarth’s research interests include clinical trials. He is Editor-in- cataract surgery; intraocular lenses; Chief of the journal of the German implants; viscoelastic, refractive laser Ophthalmological Society (DOG), technology and surgery, diagnostic Der Ophthalmologe, and a past tools, and the cornea. president of DOG. 30 Feature

13 Dan Albert 12 Rudy Nuijts 11 Renato Ambrósio

Daniel Albert is a prominent Rudy Nuijts identified the etiology A major contributor to the researcher in ocular melanoma of toxic endothelial cell destruction introduction of corneal imaging and retinoblastoma, notably on after cataract surgery (Toxic Anterior technology, Renato Ambrósio mechanisms of tumor growth and Segment Syndrome). His current also holds multiple academic inhibition. He is also a co-author research interests include innovations appointments. His work has helped and currently senior editor of Albert in corneal, cataract and refractive establish the true nature of corneal & Jakobiec’s Principles & Practice surgery, particularly the use of pathologies, from keratoconus to of Ophthalmology, a widely-used femtosecond lasers and transcleral post-LASIK dry eye, and he is a textbook. Albert previously spent 20 drug delivery. He is treasurer of strong proponent of pre-surgical years as Editor-in-Chief of Archives ESCRS, and serves on the Corneal anterior segment OCT to drive of Ophthalmology. and Educational Committees. better outcomes.

10 John Kanellopoulos 9 David Huang 8 Abhay Vasavada

A CXL expert, John Kanellopoulos Co-inventor of optical coherence A cataract/refractive surgeon and developed the Athens protocol tomography and first author of the Fellow of the Royal College of for keratoconus and ectasia, which seminal article on the topic, which Surgeons, Abhay Vasadva has great combines laser normalization of the has been cited more than 3,300 times, expertise in the successful resolution irregular cornea with cross-linking. He David Huang received the AAO’s of complicated cataract and pediatric also introduced higher fluency cross- Achievement Award in 2004. His cases. This knowledge is in great linking and prophylactic cross-linking research on refractive surgery, laser demand: Vasadva is a renowned with LASIK, a precursor to LASIK and imaging technologies combines educator and is regularly asked to Xtra, and demonstrated how CXL an understanding of laser surgery share his experiences by performing helps in infectious keratitis, corneal from both clinical and an engineering live surgery. melts and pseudophakic keratopathy. perspective.

7 Ike Ahmed 5 David Chang

Ike Ahmed is an eye surgeon who A past president of ASCRS has developed many novel treatments and current chair of the AAO and methods for glaucoma, cataract, Cataract Preferred Practice Pattern and lens implant surgery. He has Committee, David Chang is the performed pioneering work in cataract/refractive surgeon who glaucoma surgery, developing wrote what many consider to be the microinvasive glaucoma surgery, definitive textbook on the subject. MIGS (and coining the term), Chang was the first in the US to which ushered a new generation of implant a light-adjustable IOL and surgical approaches and devices the first to implant the Synchrony into ophthalmology. accommodating IOL.

6 Ioannis Pallikaris

Ioannis Pallikaris was the first to perform the LASIK procedure on a human eye. He went on to develop Epi-LASIK, and has a current research interest in corneal inlays. He is also an enthusiastic educator who has over 30 years of teaching experience in both Greece and Switzerland at undergraduate and post-graduate levels. Feature 31

4 Richard Lindstrom 3 Donald Tan 2 Amar Agarwal

Richard Lindstrom holds more than Donald Tan’s many contributions Amar Agarwal is a pioneer of thirty patents in ophthalmology, include new forms of selective lamellar microincisional cataract surgery. He having developed a number of keratoplasty, femtosecond corneal and was first to remove cataracts through solutions, intraocular lenses and refractive surgery, the Osteo-Odonto a 0.7 mm tip; first to develop no- instruments. He serves in the Board Keratoprosthesis, surgical devices anesthesia cataract surgery; first of Directors of several companies for lamellar corneal transplantation, to implant a glued IOL, and first that operate within ophthalmology, and multiple interventional myopia to use Trypan blue as epiretinal is a past president of ASCRS and clinical trials. The founder of the Asia membrane stain. Most recently, he ISRS, and a member of the ASCRS Cornea society, Tan also holds twelve and Harminder Dua (qv) have Executive Committee. patents that range from stem cell pioneered Pre-Descemet’s culture technology to novel inserters Endothelial Keratoplasty. for DSAEK surgery.

1

Theo Seiler

Theo Seiler’s doctorates in physics and medicine enabled him to become a pioneer of refractive surgery. Among his achievements are the development of the first clinical dye laser and the invention of corneal crosslinking (CXL); he also performed the first ever PTK, PRK and wavefront-laser guided surgical techniques on the human eye, and was also the first to combine LASIK and rapid CXL. Seiler founded the renowned Institute for Refractive and Ophthalmic Surgery (IROC) in 2002. iOCT Discover a new dimension with intraoperative OCT

· Proven technology for intraoperative OCT-scans of the eye´s anterior and posterior segment

· Fully integrated – using the same magnification to achieve synchronized details

· Visualization in high quality grey scales and operation via touch monitor mounted on the microscope head

HAAG-STREIT SURGICAL GmbH Rosengarten 10 D-22880 Wedel, Germany Telephone +49-4103-709 04 Fax +49-4103-709 355 [email protected] www.haag-streit-surgical.com In Practice

Surgical Procedures Diagnosis New Drugs

34-36 Selecting for Patient Success Better screening will drive better outcomes – as fewer inappropriate candidates for surgical techniques slip through the net.

32-34 Glaucoma Management Strategies When the drugs don’t work, and you want to avoid trabeculectomy, what are your options? 34 In Practice

Selecting A B for Patient Success

Using the best diagnostic tools will help ensure that the right procedures are selected for patients, driving improvements in outcomes for refractive surgery C

By Alain Saad

Eighty-five to 95 percent of the time, outcomes in cataract, refractive, and corneal inlay surgery are excellent (1,2). To help with that troublesome last 5-15 percent, we now have numerous advances in surgical technology, novel diagnostic equipment and improved patient screening at our disposal. Major Figure 2: (a) Post-LASIK microstriae. Patient complaining of his vision in this eye while uncorrected visual improvements in laser technology acuity is 20/20. (b) Double pass image of the same patient showing an increased Ocular Scattering Index that through faster excimer lasers, more explains patient symptoms. (c) Contralateral eye (post-LASIK) showing a small amount of scattering. accurate eye trackers, and very precise femtosecond lasers mean that much of Refining pre-op, intra-op and I have found the AcuTarget HD to the potential for human error during post-op outcomes be most beneficial in refining selection surgery has been eliminated. It is now The importance of objective of refractive surgery candidates by up to us to use the best diagnostic assessments of overall visual quality evaluating the optical quality of the eye devices available to ensure that patients is increasingly appreciated. Health and measuring the Ocular Scattering who are poor candidates do not slip of the tear-film, ocular light scatter, Index (OSI) (see Figure 2). When through the safety net of proper clarity of the lens and depth of focus those metrics are abnormal, surgeons screening. Here are my views on the can all impact the results of LASIK, should consider what truly is the diagnostic technologies that help to cataract and corneal inlay surgeries. best refractive surgery option for that achieve optimal outcomes. Diagnostic devices, like the AcuTarget patient. For example, an OSI above 1.5 HD (AcuFocus, Inc.), optimize means that ocular transparency is not clinical outcomes within a cataract perfect. This may be caused by an early- At a Glance and refractive practice by offering a stage cataract that can hardly be seen on • A small subpopulation of patients broader range of functionality and an slit-lamp examination, and that patient experience poor outcomes after surgery objective assessment of overall vision. may benefit from cataract surgery or • Diagnostics and screening can help This instrument monitors tear-film clear lens extraction. identify this problematic group quality over time, measures depth-of- The AcuTarget HD also evaluates • Objective assessment of overall visual focus, assesses pre- and postoperative tear film and dry eye. This is of quality is a first step inlay centration, and enhances patients’ paramount importance to refractive • Topography and aberrometry further understanding of the importance of surgeons for treating and eliminating enhance outcomes postoperative care (see Figure 1). dry eye pre-operatively, which Figure 1: Increased accommodative range in a post Kamra inlay patient. tremendously improves outcomes. As a summary, the device provides a final image, which simulates both perfect vision and the patient’s vision, enabling the surgeon to compare the two images and gain Figure 3: SCORE Analyzer showing a slightly positive score for the analyzed cornea which contra- a better understanding of what the indicates LASIK surgery in order to avoid iatrogenic ectasia. patient is seeing. It helps explain patient symptoms and thus guides us for a multifocal intraocular lens (IOL). Clinical studies toward the appropriate postoperative The aberrometer also provides the exact Research has shown that the two management. amount of corneal astigmatism and the leading causes of reduced optical quality Topographers, such as the Orbscan axis of the astigmatism, which allow after cataract and refractive surgery are (Bausch + Lomb), help refine refractive correct toric IOL implantation. uncorrected refractive abnormalities surgery outcomes by allowing us to Although I don’t use the OCT and increased media opacities that detect abnormal topographies, which (Visante, Carl Zeiss Meditec) for every cause increased light diffusion (3). are a contraindication for refractive patient group, it is useful in performing We evaluated the repeatability of surgery. The Orbscan topographical enhancements. When I am correcting measurements with a double-pass maps can be screened by SCORE myopia in a patient who has already system (4). Forty-two eyes were analyzer (Technolas Perfect Vision), undergone LASIK, OCT can determine separated into two control groups, a a new artificial intelligence system the thickness of the old flap and the post-refractive surgery group and a allows the detection of subclinical residual stromal bed, so I know the cataract group. Measurements were keratoconus (KC) with a high amount of tissue I can photoablate safely. taken using the HD Analyzer’s Optical sensitivity and specificity. I use it for Femtosecond lasers, like the iFS Quality Analysis System (OQAS, every patient’s preoperative refractive (Abbott Medical Optics), or the FS 200 Visiometrics), which measured the and cataract surgery evaluation to (Alcon) have helped refine the surgical effect of high-degree optical aberrations detect abnormality in the cornea (see procedure by increasing the safety and and loss of transparency of ocular Figure 3). the accuracy of flap incisions. Anterior tissues on the quality of the retinal An aberrometer (OPD-Scan, Nidek) and posterior stroma do not react in the image. The main outcome measures is useful for patients in whom I plan to same way to the femtosecond laser pulse, were OSI, the cutoff frequency of the implant a toric or multifocal IOL. If thus it’s important to have the data to modulation transfer function (MTF), the patient presents a large amount of enable you to program the laser settings and the Strehl ratio. high-order aberrations, preoperatively, for spot and line separation, energy level, The repeatability limit for both he or she is considered poor candidate and desired depth of the incision. groups was 0.841 (33.5%) for the OSI, 36 In Practice

8.499 (31.1%) for the cutoff MTF, instruments not only restore vision, 3. F. Díaz-Doutón et al., “Comparison of the retinal and 0.051 (31%) for the Strehl ratio. but also enhance it. As long as image quality with a Hartmann-Shack The repeatability limit was good and surgeons continue to screen patients wavefront sensor and a double-pass instrument”, equivalent for the OSI, the MTF, appropriately, they will have continued Invest. Ophthalmol. Vis. Sci., 47, 1710–1716, and the Strehl ratio values, and there success in refractive surgery outcomes. (2006). was a large gap between the normal 4. A. Saad, M. Saab, D. Gatinel, “Repeatability of and pathologic threshold for OSI References measurements with a double-pass system”, J. measurements, indicating that the 1. S.V. Kulkarni et al.,“Long-term visual and Cataract Refract. Surg. 36, 28–33 (2010). reliability of the double pass system refractive outcomes following surface ablation complies with the requirements for techniques in a large population for myopia Alain Saad is an ophthalmologist in quantitative assessment of scattering. correction" , Invest. Ophthalmol. Vis. Sci., 54, the Cornea, Cataract and Refractive We think that the double-pass system 609–619 (2013). Surgery Department (Damien Gatinel will play an important role in daily 2. S.S. Simon et al., “Achieving target refraction Department) at the Rothschild clinical practice in the near future. after cataract surgery”, Ophthalmology, 121, Foundation in Paris, France. Diagnostic and surgical planning 440–444 (2014).

Glaucoma Management Strategies

In many patients, glaucoma cannot be controlled with eyedrops, but a range of surgical techniques and drainage devices can help.

By Mark Hillen

Figure 1. The Trabecutome device handpiece. This disposable, single-use handpiece generates a bipolar electrical pulse for electrocauterization at the distal end of the tip, and performs simultaneous At a Glance irrigation and aspiration. • Trabeculectomy lowers IOP but carries significant peri- and post-operative risk Surgical intervention is required be resolved by changing the drug • Several techniques and devices have under a number of circumstances in or formulation. been developed to replace trabeculectomy patients with glaucoma. These include In such cases, surgical trabeculectomy • Less invasive developments include unacceptable intraocular pressure has historically been the intervention of trabecular meshwork stents and (IOP) levels despite maximal topical choice – and for many patients it still is. adjustable flow rate drainage devices glaucoma medication; deterioration The procedure is simple in concept – a • Identification of the best candidate in visual function or ocular structures, fistula is created to connect the anterior patients for each technique or device typically the optic disc; and adverse chamber and the subconjunctival space will become clearer as clinical reactions (either ocular or systemic) to improve drainage – but it requires experience grows to glaucoma medications that cannot considerable skill to perform, and it also In Practice 37

forms a bleb under the conjunctiva. Trabeculectomy is often highly effective at reducing IOP, but the procedure is also associated with a number of complications (see Box 1, “Trabeculectomy’s Troubles”), most of them related to blebbing. The shortcomings prompted the development of a range of instruments and devices that aim to either perform a better trabeculectomy, or manage glaucoma by different means.

Beyond trabeculectomy The Trabectome surgical technique is an alternative take on trabeculectomy developed by George Baerveldt at the University of California, Irvine, USA. It is an ab interno technique that uses high-frequency electrocautery to ablate a 60°–120° strip of the trabecular meshwork and the inner wall of Schlemm’s canal. The single- use Trabectome handpiece, connected to a console, performs three functions: electrocauterization; fluid irrigation, to stabilize the anterior chamber during the procedure; and aspiration, to remove the ablated tissue. The procedure impacts the area of greatest resistance to fluid outflow, removes debris and does not create a bleb. Figure 2. Abbott Medical Optics’ Baerveldt glaucoma device (BG 101-350). The cost of the Trabectome technique is not trivial given that, for a disposable, single-use device, it is a complex tool. It is, however, effective: data from one retrospective analysis of over 700 Trabectome procedures showed that the intervention was associated with a 40 percent decrease in IOP at 24 months after surgery (1). When combined with cataract surgery and IOL implantation, the Trabectome technique had successfully controlled IOP at one year after surgery in 87 percent of patients with exfoliation Figure 3. Alcon’s EX-PRESS shunt, which connects the anterior chamber to the intrascleral space, glaucoma and 91 percent of patients allowing drainage to a bleb. with primary open-angle glaucoma (2). 38 In Practice

Trabeculectomy’s Troubles

● Risks during surgery include subconjunctival hemorrhages or conjunctival buttonholes or tears.

● Early post-operative issues include filtering complications related to blebbing, such as early bleb leaks or failures, and hypotony or hypertony due to under or over-filtration.

● Late postoperative complications include many bleb-related events, such as late bleb failures or leaks, cystic bleb, blebitis, bleb dysesthesia or bleb-related endophthalmitis, Figure 4. Glaukos’ tiny iStent (pictured) is inserted into Schlemm’s canal, opening up that channel, plus hypotony, cataract bypassing the trabecular meshwork, and facilitating fluid flow. development or progression. Molteno implant. Non-valved devices open-angle glaucoma. They are inserted include Alcon’s EX-PRESS shunt into Schlemm’s canal, which they open (Figure 3) which, after implantation at up to let the aqueous humor drain the corneal limbus following insertion more freely; this bypasses the blocked Devices to foster fluid flow under a scleral flap, allows a limited trabecular meshwork and all without As with trabeculectomy, the concept amount of aqueous humor to drain into forming a bleb. There are also bleb-less behind implanted drainage devices the intrascleral space. stents that utilize a different outflow is straightforward. In this case, an Each of these devices has successfully pathway, namely from the anterior apparatus that causes the aqueous reduced IOP in many thousands of chamber to the suprachoroidal space. humor to drain at a faster rate from the patients with glaucoma. However, it These products, such as Glaukos’ anterior chamber to the surface of the requires skill and judgment to place iStent Supra and Transcend Medical’s conjunctiva is placed into the trabecular drainage devices safely and correctly CyPass, generate potentially very large meshwork, thus alleviating the increased in order to avoid adverse events and reductions in IOP. IOP. The device may or may not have a to obtain the best possible outcomes. Judging drainage perfectly is a valve. These device can be pure shunts In particular, bleb issues – such as bleb considerable challenge, in part because – unvalved, pure drainage devices, or encapsulation and conjunctival tissue intra-operative IOP can be different to contain valves, enabling the surgeon to thinning, and bleb infection – are not pre-operative levels, depending upon pre-set the drainage rate that’s required. uncommon (3). the type of glaucoma the patient has, The market for valve-containing New solutions are coming to the the type and location of anesthesia used, glaucoma implant devices includes three market that avoid bleb formation, and even the procedure required to place principle products: Abbott Medical such as Glaukos’ iStent (Figure 4), the the implant or shunt. Even the most Optics’ Baerveldt device (Figure 2), iStent inject, and Ivantis Inc.’s Hydrus experienced surgeon cannot predict New World Medica’s Ahmed valve, Microstent. These tiny devices are exactly what IOP reduction might and Molteno Ophthalmic’s eponymous intended for the treatment of primary be achieved; the risk of postoperative In Practice 39

A The tube can be compressed by an eccentrically shaped magnetic disk that is placed on ball bearings to allow rotation. Compression of the drainage tube, and therefore its fluidic resistance, is determined by the angle of rotation (Figure 5b). The magnetic disk can be rotated by an external control unit, providing the means of non-invasive adjustment. The device is being offered as a standalone drainage device or for use in combination with Baerveldt or Molteno implants. The pace at which glaucoma drainage techniques and technologies are evolving is rapid and their real-world impact will become clearer as more patients receive them. Analysis of the outcomes will B B then allow surgeons to determine which patients should receive what device. It is likely that different approaches will serve certain types of patient better than others, depending on the type of glaucoma and IOP reduction required, but a future can be foreseen in which all but a few patients avoid trabeculectomy.

References 1. D. Minckler et al., “Trabectome (trabeculectomy internal approach): additional experience and extended follow-up.”, Trans. Am. Ophthalmol. Soc., 106, 149–160 (2008). 2. J.L. Ting et al., “Ab interno trabeculectomy: outcomes in exfoliation versus primary open angle Figure 5. (a) The Rheon eyeWatch device, (b) a diagram showing the eccentrically shaped magnetic glaucoma”, J. Cataract Refract. Surg., 38, 315–23 (2012). disk resting on ball bearings to allow rotation. As the disk rotates, the drainage tube is increasingly 3. K.S. Schwartz, R.K. Lee, S.J. Gedde, “Glaucoma compressed, increasing the device’s fluidic resistance. drainage implants: a critical comparison of types”, Curr. Opin. Ophthalmol., 6, 181–189 (2006). hypertony or hypotony is ever-present. Such a device is now available. Called 4. A. Villamarin et al., “A New Adjustable In some cases, inadequate post-operative the eyeWatch (Figure 5a), it has been Glaucoma Drainage Device.”, IOVS, pii:iovs.13- IOP reduction can be corrected by the produced by Nikos Stergiopulos along 12626v1 (2014). doi: 10.1167/iovs.13–12626. addition (or removal) of more shunts or with a team of researchers at the École Epub ahead of print. stents. This, however, requires additional Polytechnique Fédérale de Lausanne 5. Vision 2020: The Right to Sight. www.who.int/ surgery. A drainage device could be (EPFL) in Switzerland (4) for a new blindness/Vision2020_report.pdf (2007). altered for flow resistance properties company, Rheon Medical. EyeWatch, 6. D.A. Quillen, “Common causes of vision loss in after implantation without having to which received the CE mark earlier elderly patients”, Am. Fam. Phys., 60, resort to revision surgery would be a this year, contains a drainage tube that 99–108 (1999). valuable addition to the armamentarium. includes a flow resistance controller.

NextGen

Research advances Experimental treatments Drug/device pipelines

42-44 Benchmarking DME Mining the literature to look at who’s publishing what and where. 42 NextGen

Benchmarking DME

What does analysis of the Most frequent topics on PubMed last five years of literature on diabetic macular edema Diabetic retinopathy tell us about the priorities of the field and the major Macular edema contributors to it? Visual acuity Tomography, optical coherence By Mark Hillen Vitreous body Treatment outcome Diabetic macular edema (DME) is the major cause of vision loss in Injections people with diabetic retinopathy – Fluorescein angiography if a person has diabetes, they have a Laser coagulation 1 in 10 chance of developing DME Vascular endothelial growth factor during their life. The raw numbers are chilling: the International Diabetes Angiogenesis inhibitors Federation estimates that in 2011 Prospective studies that there were 366 million people Retina with diabetes, and they predict this Retrospective studies to rise to 552 million by 2030 (1). To provide insight into the past Follow-up studies and predictions for the future of the Antibodies, monoclonal Articles in field, a series of metrics were applied Glucocorticoids MEDLINE are to the last five years of the published indexed by Medical literature. We asked: Triamcinolone acetonide Subject Headings (MeSH) Diabetes mellitus, type 2 topics, that describe the articles’ main topics. Here are the top • What are the major topics for Aged, 80 and over 25 MeSH terms over the last the field? Vitrectomy • Which publications have the five years of the human greatest impact? Macula lutea DME literature. • How is the knowledge Diabetes mellitus, type 1 available online? Retinal vein occlusion • Who are the most prolific authors? Intravitreal injections PubMed, was searched for diabetic macular edema* with results limited 0 50 100 150 200 250 300 to the last five years, in humans (for a clinical focus). The data were Publications (n) analyzed in Microsoft Excel 2013.

Reference DME 1. D.R. Whiting et al., “IDF diabetes atlas: publications 2010 2012 global estimates of the prevalence of per year 2011 diabetes for 2011 and 2030”, Diabetes 228 214 2009 Res. Clin. Pract., 94, 311–21 (2011). doi: 190 10.1016/j.diabres.2011.10.029. 152 Top 12 journals (number of publications) Journal Impact Factors for 2013

Retina Diabetes Care 7.735

Ophthalmology Ophthalmology 5.563

Invest Ophthalmol Vis Sci Arch Ophthalmol 3.826

Am J Ophthalmol Am J Ophthalmol 3.631

Acta Ophthalmol Invest Ophthalmol Vis Sci 3.441

Eye (Lond) Curr Diab Rep 3.165

Ophthalmologica Retina 2.825

Graefes Arch Clin Exp Ophthalmol Br J Ophthalmol 2.725

Br J Ophthalmol Acta Ophthalmol 2.345

Arch Ophthalmol Graefes Arch Clin Exp Ophthalmol 1.932

Eur J Ophthalmol Eye (Lond) 1.818

Ophthalmic Surg Lasers Imaging Curr Eye Res 1.71

0 20 40 60 80 100 120 0 1 2 3 4 5 6 7 8

Categorization of articles Fee or free? Case report Unavailable online Free full text Review Clinical 6% trial 10% 23% 37% 19%

6% 37% Letter 67% Full text upon Comparative payment/ study subscription

Articles are categorized according to PubMed criteria. Clinical study represents a clinical evaluation of a drug, device Just under one in every four articles are available online, or technique that was not a clinical trial. free of charge. However, a tenth are still unavailable online. Diabetes Care 0.11379 Invest Ophthalmol Vis Sci 0.08357 Ophthalmology 0.06002 Am J Ophthalmol 0.03945 Br J Ophthalmol 0.031 Arch Ophthalmol 0.02639 Retina 0.01817 Eye (Lond) 0.01449 Graefes Arch Clin Exp Ophthalmol 0.01368 Acta Ophthalmol 0.01099 Curr Eye Res 0.00587 Eur J Ophthalmol 0.0051 Curr Diab Rep 0.00459 Jpn J Ophthalmol 0.00373 Can J Ophthalmol 0.00355 Ophthalmic Surg Lasers Imaging 0.0033 J Ocul Pharmacol ‹er 0.00267 Ophthalmologica 0.00258 Ophthalmologe 0.00249 Klin Monbl Augenheilkd 0.00166 Curr Diabetes Rev 0 Korean J Ophthalmol 0 Klin Oczna 0 44Indian J OphthalmolNextGen 0 Int Ophthalmol 0

0.00 0.02 0.04 0.06 0.08 0.10

Most prolific authors in DME, 2009–2013

21 Wong TY 19 Aiello LP 18 Bressler NM 17 Yoshimura N 17 Nguyen QD 16 Glassman AR 15 Schmidt-Erfurth U 15 Murakami T 15 Bandello F 14 Nishijima K 14 Klein R 14 Beck RW 13 Massin P 13 Do DV 12 Scott IU 12 Mitchell P 11 Wu L 11 Sivaprasad S 11 Lamoureux EL 11 Ferris FL 11 Danis RP 11 Campochiaro PA 11 Bressler SB 10 Horii T 10 Arevalo JF

0 5 10 15 20

Average journal Eigenfactor score

Diabetes Care 0.11379 Invest Ophthalmol Vis Sci 0.08357 Ophthalmology 0.06002 Am J Ophthalmol 0.03945 Br J Ophthalmol 0.031 Arch Ophthalmol 0.02639 Retina 0.01817 Eye (Lond) 0.01449 Graefes Arch Clin Exp Ophthalmol 0.01368 Journals Acta Ophthalmol 0.01099 are rated Curr Eye Res 0.00587 according to the number Eur J Ophthalmol 0.0051 of incoming citations, with Curr Diab Rep 0.00459 Jpn J Ophthalmol 0.00373 citations from highly ranked Can J Ophthalmol 0.00355 journals weighted to make a 1 publication Ophthalmic Surg Lasers Imaging 0.0033 larger contribution to the J Ocul Pharmacol ‹er 0.00267 citations Ophthalmologica 0.00258 Eigenfactor than those 2.601 Ophthalmologe 0.00249 from poorly ranked Klin Monbl Augenheilkd 0.00166 Curr Diabetes Rev 0 journals. Korean J Ophthalmol 0 Klin Oczna 0 Indian J Ophthalmol 0 Int Ophthalmol 0

0.00 0.02 0.04 0.06 0.08 0.10

21 Wong TY 19 Aiello LP 18 Bressler NM 17 Yoshimura N 17 Nguyen QD 16 Glassman AR 15 Schmidt-Erfurth U 15 Murakami T 15 Bandello F 14 Nishijima K 14 Klein R 14 Beck RW 13 Massin P 13 Do DV 12 Scott IU 12 Mitchell P 11 Wu L 11 Sivaprasad S 11 Lamoureux EL 11 Ferris FL 11 Danis RP 11 Campochiaro PA 11 Bressler SB 10 Horii T 10 Arevalo JF

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TheOphthalmologist_jan2014_FEMTO_LDV_Arcuate_Inscisions_Ad_210x266.indd 1 17.01.14 15:20

Profession

Your career Your business Your life

48-49 Quality Family Time at a Congress Next time you need to attend an event, think about taking your family to share the experience. 48 Profession

the family. The first task is to map out add a new dimension to packing for a Quality Florian’s schedule, to determine when working vacation. Sure, pack enough he needs to present his work, which clothing, toys and reading materials to Family Time sessions he would like to go to, and make it through the trip, but the most what activities he needs to attend in the important holdall is the travel bag: at a Congress evenings. From that starting point, it’s include everything you might need surprising how much time the family for an unwell toddler. In addition to Grasp the opportunity to can have together – I definitely see diapers and diaper cream, I pack fever take the whole family to more of my husband when we travel medication, sun cream, nasal spray, conference locations – and than when he is at home. wipes, baby teething paste, and so on. gain a new perspective on the The second issue to factor in is It’s not fun when a distressed, snotty places you visit. schooling. With our eldest child, infant with a fever wakes up all of the schooling comes first. We try to travel family at three o’clock in the morning, By Nicole Kretz during school holidays, but when that isn’t but it’s so much more worse if you are possible we bring homework bags and set not prepared. Our family is pretty typical. My strict guidelines about study times. That If Florian is travelling at his own husband, Florian, and I have two means there’s no arguing, and when we expense we book flights and hotels children: a son, aged thirteen, and do explore the cities that we visit, we can together as a family. Things are more a daughter, aged four. Florian’s do it together and have fun. difficult if the trip is paid for and regular attendance at ophthalmology The third consideration is where we arrangements conducted through conferences around the world presents will stay. Often the congress hotels are a travel company. We can ask if the us with a choice: the rest of us either stay quite expensive, and as a family, we’re children and I can also travel on at home, and miss our father/husband, paying our own way. In addition, when the same flights and stay in a bigger or we pack our bags and go to the you’re with children it can be awkward room in the hotel at our expense, but conferences together. We often choose being in a luxury hotel, and a five- flights are sometimes fully booked the second option. Doing so needs star restaurant is a waste of money if or prohibitively expensive. We then careful planning, but we are rewarded I can’t sit with my daughter singing have to consider later flights and with being together, seeing the world, quietly or drawing in her coloring-in alternative accommodation. and (with a little effort) having some book. I don’t want half of the clientele amazing experiences along the way. wishing we were on a different planet. When you’re there However, some business hotels are Sometimes the family and Florian’s Planning family-friendly and most restaurants work can mix – it all depends on the Communication is the key to planning will make a special effort to make environment. A cocktail dinner is not a working vacation that’s fun for all of some toddler-friendly food or a treat appropriate for children, but a dinner younger children. at a museum with nibbles can be – we There’s a good alternative to hotels: can walk around freely and explore At a Glance it’s often much less expensive for our the venue – and I find that our most • Working vacations are an opportunity family to stay in an apartment with a congress-goers are quite happy to talk for the whole family to have small kitchen. We can prepare meals, about topics unrelated to eyes! Keeping new experiences have breakfast together and just children entertained is important (some • A well-planned itinerary and a generally have more room to relax in. museums are more interesting to them sensible approach is crucial The criteria I use are a good location, than others) so I bring small games or • Flexibility around work commitments affordability, comfort and practicality. a coloring-in book with crayons, and is a must We study maps, and read the reviews iPhone apps, particularly educational • Connect with the families of colleagues on websites like Tripadvisor and Airbnb. ones. Being flexible is the key: if the and make new friends You can’t have a successful vacation dinner is boring, I may take the children • An inquiring mind guarantees a without good packing organization. outside to play. Sometimes other rewarding experience Children – particularly toddlers – congress attendees have brought their Profession 49

children along, and they all quickly For example, AAO 2012 in Orlando being interested in the culture and become friends. It’s always a pleasure to was great. The kids loved Sea Life asking questions. I was even invited meet other parents who want to include and Disney World and afterwards into kitchens to learn how to make their children. we had a beach vacation in Daytona. bread and a real tagine, and we were When Florian is working, we get out For ASCRS 2013 in San Francisco, shown the real off-the-tourist-map and explore. Orientation group tours we rented an apartment and included city. That was a bumpy ride (honestly, are great for helping to discover the area Florian’s colleagues into our family, it really seemed that the car door with the aid of a guide. Tourist centers which was fun and a fantastic bonding might fall off ) but we were always are usually fantastic, offering all the help experience. ESCRS in 2011 was safe and well taken care of. A small you need find interesting places to visit in Vienna, and for that we rented gesture that comes with a big heart is and everything you need to navigate, an apartment that was close to the always appreciated. including maps, timetables and the best conference, with Florian’s aunt and Overall, working vacations can advice for dealing with taxi drivers. Of uncle. When Florian was working, we be a great way of combining work course, good hotels always have someone saw all the sights of the city, visiting and quality family time. With good to help too. I find concierges to be really museums and the Prater, and when he communication, organization, realistic helpful and full of great advice. Even had time off we did the activities he goals and a relaxed approach you can your smartphone can help. Google most enjoyed. Planning ahead meant it explore the world together and make and Google Maps can give you almost worked out perfectly. lasting memories for your family and everything you need (assuming you can The best advice I can give when you great connections with your colleagues. obtain free Wi-Fi), and Yelp is fantastic are out and about with your children for finding good restaurants, museums is to talk to people. For example, Nicole Kretz is a mother of two young and fun things to do. when we visited Morocco, we learned children, wife of an ophthalmologist, and We’ve had some memorable trips. so much from local people just by a keen world traveler. Calling the Plays for Alimera

Sitting Down With Dan Myers, President and CEO of Alimera Sciences, Inc. Sitting Down With 51

Where did your journey to almost from nothing – something Alimera begin? that I’ve repeated with Alimera. To “I don’t constrain people; I actually grew up in Atlanta, not far complete the chronology, in 1996, from where Alimera is based today. In was formed by the merger I give them freedom to my younger days, I was very proficient in of CIBA-Geigy and Sandoz, and so express themselves.” sports and attended Georgia Tech on an we became Novartis Ophthalmics. American football scholarship. I played Soon afterwards I became President quarterback; a position that leads the of the division, a position that I held the staff to come to work at Alimera offence and decides what we do on the between 1997 and 2002, during which motivated, every day, to do their best field. It involved quick thinking under a time we launched the first drug that – and I try to build an environment lot of stress, and I think that experience could be used to treat retinal disorders: where that happens. I can’t be running helped with my subsequent career. Visudyne, back in 2000. around personally motivating everyone Thankfully though, I also realized that but I want the workplace to be Georgia Tech was a great school, with a How did Alimera come about? motivating. We are not your typical lot to offer academically, so I decided to Novartis decided to rationalize giant pharmaceutical company, so apply myself with as much effort to my its operations and move Novartis we don’t have their highly defined industrial management studies as I did Ophthalmics to New Jersey. I knew that structures and procedures and some to my football. I wanted to remain in Georgia so I and people coming from that background my fellow founders of Alimera pooled find our approach slightly daunting at What took you into ophthalmology? our severance packages and also raised first, but they quickly realize that the I started in ophthalmology in the venture capital funding. Fortuitously, freedom and flexibility that Alimera early 1980s as an Allergan sales rep this was just after the dotcom bubble provides results in a driven group that in Atlanta, spending about a year burst and investors wanted to back enjoy their work. I also like a bit of carrying the bag, travelling from doctor companies with more than just IP emotion. In meetings I want people to to doctor. It was another valuable and a website – and healthcare was tell me exactly what they believe; if they experience. Next, I spent about three something that they were prepared to have differing opinions, I want to hear years outside of ophthalmology with back. I used to hear that “money follows from them. When we make a decision, American Hospital Supply, but came management” and it seems to be true: we get behind it completely – I often back and worked with Johnson and the VCs valued the management say that we get 100 percent behind a 51 Johnson, this time in Los Angeles, experience of the team, and we raised percent decision. who had acquired Cooper Vision $60 million. Soon afterwards I met Paul Pharmaceuticals. There I had my first Ashton, of pSivida, (who developed the You have also served on the Carter taste of being an entrepreneur as I was advanced drug-delivery technology Foundation Board of Councilors. involved in assimilating that acquisition that’s in ILUVIEN) and within a Yes. The Carter Foundation has two into their Iolab division. But I wanted to couple of hours, we knew that we had main goals in ocular health: the control move back to Atlanta, and when I heard something special. It was serendipitous; and elimination of river blindness and that CIBA Vision (who were based in we were together at the right place at trachoma, and I was genuinely honored Atlanta at the time) were diversifying the right time. to be invited to contribute my time to into the ophthalmic pharmaceutical the Foundation and to sit on the board. business, I jumped at the chance to What’s the management style for I was very fortunate to meet President become one of the founding members building successful businesses? Carter for dinner on one occasion, and of CIBA Vision Ophthalmics. It was I don’t constrain people; I give them I found him to be a genuine, intelligent a small team building a business unit freedom to express themselves. I want and honorable man. ILUVIEN® is indicated for the treatment of vision impairment associated with chronic diabetic macular oedema (DMO), considered insufficiently responsive to available therapies.

FOR INSUFFICIENTLY RESPONSIVE DMO 36 MONTHS OF SUSTAINED TREATMENT ACHIEVABLE WITH ONE INJECTION 1,2

NICE RECOMMENDS ILUVIEN (TA301)3 for treating chronic diabetic macular Human Aqueous Concentrations of Fluocinolone Acetonide (FAc) With 1 Implant1 oedema that is insufficiently responsive to ■ ILUVIEN® provides 3.5 available therapies in pseudophakic eye under at least 36 months of 3 in vivo drug delivery1 a patient access scheme. 2.5 2 For further details, see http://guidance.nice.org.uk/TA301 1.5

1 Concentration of FAc (ng/mL) Concentration of FAc 0.5

0 0 3 6 9 12 15 18 21 24 27 30 33 36

Time (months) ILUVIEN (0.2 µg/d)

Percentage of Patients With ≥15-Letter Response Over Baseline (chronic DMO)1

■ Significantly more patients 40

with chronic DMO treated 35 34.0% with ILUVIEN achieved 30 P<.001 ≥15-letter improvement 25 over baseline at month 20 1,2

36 vs control (%) Patients 15 13.4% 10 ■ 76.1% of chronic DMO 5 patients received 1 implant 0 in 3 years, the remaining 0 3 6 9 12 15 18 2124* 27 30 33 36 patients received 2 or Time (months) 2 more implants ILUVIEN (0.2 µg/d) n=209 Control n=112 *Primary readout.

Prescribing Information can be found on the back of this page.page Learn more at: ILUVIEN.co.uk

Please visit us during the RCO at stand D 36 MONTHS OF SUSTAINED TREATMENT ACHIEVABLE WITH ONE INJECTION 1,2

Market research suggests that many DMO patients do not achieve optimal outcomes.4

4 DMO Quantitative Market Research Survey Spectrum of BCVA levels over the long term for DMO patients Results from third-party survey of 180 retina-treating ophthalmologists in EU.*

■ In the study, retina-treating ophthalmologists 43.8% 24.3% 31.9% estimated 56.2% of DMO patients experience Achieve 6/12 or better Achieve 6/18 Stayed at 6/24 or worse poor vision outcomes (6/18 or worse) long term (20/40) (20/60) (20/80) *Survey conducted in UK, DE, FR, AT, IT, ES, PT from 26 April to 9 September 2012. 56.2%

ILUVIEN® has the potential to provide chronic DMO patients with improved visual acuity at 36 months compared with baseline.1,2 Learn more at: ILUVIEN.co.uk

To request more product information, email [email protected] or call 0800 148 8274

ILUVIEN® Prescribing Information Refer to the Summary of Product Characteristics (SPC) before prescribing. response to the first implant is known. Interactions: No interaction studies with other medicinal products Presentation: intravitreal implant in applicator. Each implant contains 190 micrograms of fluocinolone have been performed. Pregnancy and lactation: There are no adequate data from the use of intravitreal acetonide. Light brown coloured cylinder, approximately 3.5mm x 0.37mm in size. Implant applicator with 25 administered fluocinolone acetonide in pregnant women. ILUVIEN is not recommended during pregnancy gauge needle. Indication: ILUVIEN is indicated for the treatment of vision impairment associated with chronic unless the potential benefit justifies the potential risk to the foetus. ILUVIEN is not recommended during breast diabetic macular oedema, considered insufficiently responsive to available therapies. Dosage and method of feeding unless clearly necessary. Driving and using machines: Patients may experience temporarily administration: The recommended dose is one ILUVIEN implant in the affected eye. Administration in both eyes reduced vision after administration of ILUVIEN and should refrain from driving or using machines until this has concurrently is not recommended. An additional implant may be administered after 12 months if the patient resolved. Undesirable effects: Very common (≥ 1/10): cataract operation, cataract, increased intraocular experiences decreased vision or an increase in retinal thickness secondary to recurrent or worsening diabetic pressure, floaters (myodesopsia); common (≥1/100 to < 1/10): glaucoma, trabeculectomy, eye pain, vitreous macular oedema. Retreatments should not be administered unless the potential benefits outweigh the risks. haemorrhage, conjunctival haemorrhage, blurred vision, glaucoma surgery, reduced visual acuity, vitrectomy, Only patients who have been insufficiently responsive to prior treatment with laser photocoagulation or other trabeculoplasty; uncommon (≥1/1,000 to < 1/100): endophthalmitis, headache, retinal vascular occlusion, available therapies for diabetic macular oedema should be treated with ILUVIEN. Children under 18: No relevant optic nerve disorder, maculopathy, optic atrophy, conjunctival ulcer, iris neovascularisation, retinal exudates, use. Special populations: No dosage adjustments are necessary in elderly patients, or those with renal or vitreous degeneration, vitreous detachment, posterior capsule opacification, iris adhesions, ocular hepatic impairment. Contraindications: the presence of pre-existing glaucoma or active or suspected ocular hyperaemia, sclera thinning, removal of extruded implant from sclera, eye discharge, eye pruritus, extrusion or periocular infection including most viral diseases of the cornea and conjunctiva, including active epithelial of implant, implant in line of sight, procedural complication, procedural pain. Consult the SPC for full details of herpes simplex keratitis (dendritic keratitis), vaccinia, varicella, mycobacterial infections, and fungal diseases. undesirable effects. Overdose: No case of overdose has been reported. Legal classification: POM. Pack size Hypersensitivity to the active substance or to any of the excipients. Special warnings and precautions: and NHS list price: £5,500.00 (ex VAT) for each ILUVIEN 190 micrograms intravitreal implant in applicator. Intravitreal injections have been associated with endophthalmitis, elevation in intraocular pressure, retinal Marketing Authorisation number PL41472/0001. Marketing Authorisation Holder: Alimera Sciences detachments and vitreous haemorrhages or detachments. Patients should be instructed to report without delay Limited, Centaur House, Ancells Business Park, Ancells Road, Fleet, GU51 2UJ UK. Date of preparation of PI: January 2014 any symptoms suggestive of endophthalmitis. Patient monitoring within two to seven days following the injection may permit early identification and treatment of ocular infection, increase in intraocular pressure or Adverse events should be reported. Reporting forms and information can be found other complication. It is recommended that intra-ocular pressure be monitored at least quarterly thereafter. Use at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Alimera of intravitreal corticosteroids may cause cataracts, increased intraocular pressure, glaucoma and may increase Sciences Limited (telephone: 0800 148 8274) [email protected] the risk of secondary infections. The safety and efficacy of ILUVIEN administered to both eyes concurrently have not been studied. Concurrent treatment of both eyes is not recommended until the patient’s systemic and ocular For medical enquiries please email: [email protected]

References: 1. ILUVIEN, Summary of Product Characteristics. 2. Campochiaro PA, Brown DM, et al. Ophthalmology 2012; 119: 2125-2131. 3. NICE technology appraisal guidance 301 (issued November 2013): Fluocinolone acetonide intravitreal implant for treating chronic diabetic macular oedema after an inadequate response to prior therapy (http://guidance.nice.org.uk/TA301) 4(8). Data on file. Alimera Sciences.

© 2014 Alimera Sciences Limited Date of preparation: April 2014 UKILV0107 AMARIS® 1050RS AMARIS® 750S AMARIS® 500E

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