OCTOBER 2016 # 34 Upfront In Practice Profession Sitting Down With Keeping an eye Keratoplasty: Applying clinical trial data to The master of macular on Zika challenging convention your practice degeneration, Philip J. Rosenfeld 14 32 – 38 44 – 46 50 – 51 Forging Iron Man History is made: the story of the first clinical use of a robot in eye surgery 18 – 29 www.theophthalmologist.com ADVANCING TOGETHER 11707-Alcon-Surg-OPHTHALMOLOGIST-OCTOBER-ISSUE-OUTLINED.indd 1 05/09/2016 13:49 Image of the ADVANCING Month TOGETHER Confetti Cornea A cornea from a K14CreER-Confetti mouse containing the four color Brainbow reporter cassette. The multicolored radial streaks develop after induction of the transgene with tamoxifen, and arise from Keratin 14-expressing progenitor cells, positioned in the limbal annulus. Nick Di Girolamo and his colleagues developed the model to better understand basic corneal biology and how stem cells function to replenish the cornea throughout life. Nick says “This model lends itself beautifully to studying when corneal stem cells are designated, their destiny during aging, and how they behave during corneal wounding and following transplantation. We believe this technology will be used to help address some of the controversies and limitations that have plagued our field for decades. Our ultimate goal is to translate our findings to the clinic.” Image courtesy of Associate Professor Nick Di Girolamo from the School of Medical Science, University of New South Wales, Sydney, Australia. Do you have an image you’d like to see featured in The Ophthalmologist? Contact [email protected]. www.theophthalmologist.com 11707-Alcon-Surg-OPHTHALMOLOGIST-OCTOBER-ISSUE-OUTLINED.indd 1 05/09/2016 13:49 Contents 14 In My View 16 Robert Ritch puts forward the case for iridoplasty as an effective means of opening an appositionally closed angle, and 18 shares his experiences with the technique. 17 Is a more integrated approach for keratoconus needed? Rohit 03 Image of the Month Upfront Shetty and his colleagues discuss the unmet needs in keratoconus, 08 The MHC Matchmaker and a potential solution. 07 Editorial Back to the Future, 09 Number Games by Mark Hillen 10 Visualizing Vision Feature 11 Sleep Easy 18 Forging Iron Man On The Cover As eye surgery moves to the OCTOBER 2016 # 34 14 Cry Me a Zika future, we feature what will Upfront In Practice Profession Sitting Down With Keeping an eye Doing the right surgery Getting gene therapies into Glaucoma mentor, on Zika – in the wrong eye! the clinic Harry Quigley 12 38 – 39 47 – 49 50 – 51 A depiction of Robert MacLaren become a historic moment Forging Iron Man History is made: the story of the first clinical use of a robot in eye surgery 18 – 27 in the Iron Man suit. 15 This Month in Business in ophthalmology: the first robotic-assisted eye surgery www.theophthalmologist.com on a live patient. ISSUE 34 - OCTOBER 2016 Editor - Mark Hillen [email protected] Associate Editor - Roisin McGuigan [email protected] Associate Editor - Ruth Steer [email protected] Editorial Director - Fedra Pavlou [email protected] Content Director - Rich Whitworth [email protected] Publishing Director - Neil Hanley [email protected] Sales Manager - Abigail Mackrill [email protected] Head of Design - Marc Bird [email protected] Designer - Emily Strefford-Johnson [email protected] Junior Designer - Michael McCue [email protected] Digital Team Lead - David Roberts [email protected] 44 Digital Producer Web/Email - Peter Bartley [email protected] Digital Producer Web/App - Abygail Bradley [email protected] Digital Content Assistant - Lauren Torr [email protected] Audience Insight Manager - Tracey Nicholls [email protected] Traffic and Audience Associate - Lindsey Vickers [email protected] Traffic and Audience Associate - Jody Fryett [email protected] Social Media / Analytics Associate - Ben Holah [email protected] Events and Office Administrator - Alice Daniels-Wright [email protected] Financial Controller - Phil Dale [email protected] 50 Chief Executive Officer - Andy Davies [email protected] Chief Operating Officer - Tracey Peers [email protected] Change of address [email protected] 32 Tracey Nicholls, The Ophthalmologist, Texere Publishing Limited, Haig House, Haig Road, Knutsford, Cheshire, WA16 8DX, UK. Profession Single copy sales £15 (plus postage, cost available on request [email protected]) 44 Analysis Paralysis Annual subscription for non-qualified recipients £110. Do you find stats simple or scary? General enquiries: www.texerepublishing.com Marco Zarbin shares his insights [email protected] on how to approach clinical trial +44 (0) 1565 745 200 In Practice data and apply it to your practice. [email protected] Distribution: The Ophthalmologist (ISSN 2051-4093) 32 Challenging Convention is published monthly except July, by Texere Martin Dirisamer considers the Publishing Ltd and is distributed in the USA by UKP Worldwide, 1637 Stelton Road B2, future of endothelial keratoplasty, Sitting Down With Piscataway, NJ 08854. and talks about how surprising Periodicals Postage Paid at Piscataway, NJ and additional mailing offices findings from a DMEK post- 50 Philip J. Rosenfeld, Professor of POSTMASTER: Send US address changes to surgical complication may lead Ophthalmology, Bascom Palmer The Ophthalmologist, Texere Publishing Ltd, us there. Eye Institute, Miami, Florida. c/o 1637 Stelton Road B2, Piscataway NJ 08854 Reprints & Permissions – [email protected] Start Nano-Laser Cataract Surgery today. Single-use hand pieces. LESS RISK OF INFECTIONS No moving needle. NO TEMPERATURE GRADIENT Works with every Phaco. SAVES TIME AND MONEY No other laser cataract surgery system comes even close: NANO-LASER. Bessemerstr. 14 90411 Nürnberg www.arclaser.com Germany [email protected] +49 (0) 911 217 79 -0 OT_2016_FullPage.indd 1 04.10.2016 17:11:05 Back to the Future Editorial Don’t fear the robots. They might help ophthalmologists cope with the huge, oncoming caseload of aging baby boomers. his month’s cover feature tells the story of the first ever clinical use of robotic assistance in eye surgery. Robert MacLaren invited me down to Oxford to Tcover it. I was honored, and lucky to be there – the only other external media present were the BBC. It’s only being published in this issue, as we had to respect an embargo not to release coverage until the BBC had. This has been our first opportunity to tell that story, and I urge you to turn to page 18 as soon as you’ve read this editorial (if not, sooner). We’ve written about the robotic retinal dissection device (R2D2) used in the surgery before (1) – Marc de Smet, who serves as the Chief Medical Officer of R2D2’s manufacturer, Preceyes, detailed everything about the robot; how it works, what it can do, and how such technology can be, to quote Asimov, “better than the best of humans.” It certainly felt like the future when we published the article. Now we’re revisiting it, it feels like we’re going Back to the Future. Articles like these are the kind I enjoy the most. They speak to the future of ophthalmology, they tell the stories behind the work that’s going to open up whole new ways of treating ocular disease, and revolutionize how surgeons will work in the future. We all know that there aren’t enough ophthalmic surgeons being trained to deal with the onslaught of aging baby boomers with age-related eye disease that are already filling clinics to the brim and extending the workload of surgeons well beyond the 9-to-5 they’d be delighted to work. I think the rise of robots during surgical procedures is a prime Reference example of necessity being the mother of invention. Unless 1. M de Smet, “Eye, Robot”, The you want significant portions of the post-war generation to go Ophthalmologist, 15, 18–25 (2015). undertreated and rendered increasingly more dependent on the help of others to get by – for the sake of a treatable ophthalmic disease – advances like these robots have to be made. There is one thing I’ve noted – nobody wants to see autonomous surgical robots (even though that’s technically feasible in some procedures elsewhere in the body even today). It looks like if robots are to be adopted, surgeons will remain in control for a long time to come. One thing is for certain though, there’s no stopping them. The robots will soon be here. I, for one, want to welcome our new robot overlords – you. Mark Hillen Editor www.theophthalmologist.com 8 Upfront The MHC Upfront Matchmaker Reporting on the When it comes to innovations in medicine transplanting stem cell- and surgery, the research derived RPE, if it’s allogeneic, policies and personalities match the MHC that shape the practice Sugita. Sunao Credit: Ophthalmic research has been at of ophthalmology. the forefront of the drive for clinical Figure 1. The results of transplanting translation, and the use of human MHC-matched or -mismatched allografts induced pluripotent stem cells (iPSCs) using iPSC-derived RPE cells (iPS-RPE) We welcome suggestions for the treatment of retinal disease like established from a MHC homozygote donor (1). on anything that’s AMD is a striking example of this. impactful on You can take, say, a skin epithelial cynomolgus monkeys, shown that you can ophthalmology; please cell, induce pluripotency, and soon successfully use allogeneic iPSC-derived you have a self-renewing reservoir of RPE cells, without immunosuppression, email mark.hillen@ cells that can be differentiated into so long as those iPSCs come from a texerepublishing.com almost every cell type, including RPE, MHC-matched donor (Figure 1). If the which can then be implanted to try iPSCs came from a MHC-mismatched and treat disease.