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The European Society of Cataract and Refractive Surgery (ESCRS) conference is particularly well placed in the refractive industry's calendar - between the two major American refractive/ophthalmic meetings, the American Society of Cataract and Refractive Surgery and the American Academy of Optometry. It is fair to say that new products aimed at global domination tend to get released at the AAO which follows the ESCRS. Why wouldn't companies release technology to the 30,000 people that attend the event?

One lesson to quickly learn in this industry, however, is never to under-estimate the smaller ESCRS. The punch it packs and its specialised nature makes it a perfect forum for new technology and justifies its place in an event which is so important in refractive surgery.

Mergers and takeovers

It's an interesting time in this sector, although it's hard to remember a time when this statement would not be true.

In the US, corporate bodies have been busy buying up each other, merging, or in some cases failing to buy each other. Europe is, of course, by no means unaffected by this US activity - quite the contrary. For example, Germany's WaveLight, which manufactures the Allegretto suite of lasers, have become part of US-based giant Alcon. The current negotiations with competition authorities in numerous non-US countries say much about the potential influence of the deal.

US-based AMO's takeover of Intralase also has substantial effects on Europe, particularly as Intralase edges ever closer to becoming a Lasik flap-creating standard of care. Even AMO's failed attempt to somewhat ambitiously takeover the much larger Bausch & Lomb had effects on European market perception. Certainly conversations about this event, or non-event as the case may be, were frequent in the Stockholmassan Conference Centre. As, of course, were conversations surrounding the actual deal with Bausch & Lomb private equity group Warburg Pincus was busy closing this merger at the time of the ESCRS meeting.

All this activity reminds us what a truly global market refractive surgery has become, how inter-related the continents are and how ultimately this has to be good for everyone. The ESCRS reflects this global nature with talent from every corner of the planet taking part. Three of every five delegates hailed from somewhere other than western Europe.

Excimer laser

Excimer laser usually springs to mind in the when refractive surgery is mentioned. This has been true for many years, although relatively few major changes to this area have occurred.

The recent global market for purchases of new excimer lasers is modest when the effects of India and China are excluded. Sparse offerings of new lasers were presented in Stockholm. Schwind displayed its new Amaris model, which has some nice features including cyclo-rotational tracking. This is the final frontier of eye-tracking. Excimer lasers mostly follow eye movement in the horizontal and vertical planes, and moving towards or away from the laser head. They can also tell if the eye has rotated a bit at this start of treatment.

Presbyopia

The concept of a presbyopic correction delivered via an excimer ablation pattern continues to lack credibility among the majority. Presbyopia itself, however, remains one of the key topics at these meetings, and is likely to remain so for the foreseeable future.

The fact that presbyopia is inextricably linked to age, and therefore IOLs, means the range of options for a surgical correction is extensive. Options lead to debate, debate leads to a lack of any one technique for all patients becoming firmly established, and this is a fair summary of the situation with presbyopia.

Conductive keratoplasty, accommodative and diffractive IOLs, monovision, excimer presbyopic ablation profiles, scleral techniques and corneal inlays all offer surgical presbyopic correction. CK and presbyopic IOLs work exceptionally well for selected patients, but the definitive technique for all remains elusive. Corneal inlays are generating the most interest as the current suitor to that task. Think of a corneal inlay as an extraordinarily thin polymer to be surgically inserted into the corneal tissue. There are three current corneal inlay options with three very different mechanisms to presbyopic correction.

The AcuFocus certainly appears to be the front-runner if total discussion minutes were anything to go by. Its pin-hole mechanism benefiting depth of field produced some impressive data. The list of surgeons involved in the clinical trials reads like a 'who's who' of refractive surgery, demanding the product is taken seriously. The size of market, the upgradeable nature of the device itself, and the Intralase precision to assist the fitting and authority of surgeons involved in the trials all suggest this will evolve into a major product. The relatively cautious nature of AcuFocus's commercial release is probably the right thing to do, as launching too early has risks. Remember the name AcuFocus, it might just become the presbyopic-correcting brand in a wide open market.

The other two corneal inlays either work on relative steepening of the central cornea or simply adding plus power. Two of the three inlays boasting their respective CEO's personal experience of their own outcome with the inlay did not go unnoticed. No scientific value but a something of a comfort factor when a device is still in clinical trials.

Femtosecond technology

Femtosecond-related technology has been buzzing around the major events in recent times. Intralase dominates the femtosecond part of the market and there is no immediate sign of this changing. There seems little debate on the superiority of the device when compared to mechanical blade methods of creating a Lasik flap. Assembling a mechanical device to create a flap is already looking a bit old-fashioned. Femtosecond is unquestionably the future for Lasik. The only question is when, not if, it moves from best practice to standard of care.

Paper after paper at Stockholm kept finding superior repeatability, safety and precision. Perhaps what is now most impressive, as the debate on clinical preference for creating a Lasik flap goes quieter, is the ever-widening uses for the technology. Implantation of intacs, penetrating keratoplasty, femtosecond-prepared posterior endothelial donor DSAEK, ablation of the posterior capsule following cataract surgery and numerous others were put forward in clinical papers.

One worthy of a specific mention is the 'FLEX' technique by Zeiss. Imagine a flap created by a Zeiss-manufactured femtosecond laser. Rather than using a second laser to reshape the underlying cornea, a lenticule of stromal tissue is removed, leaving a precise shape and correcting the prescription as it does so. All fine in theory. The results are reasonable at this early stage of the technique, not as good as modern wavefront-guided excimer laser treatment. It is all early in the learning curve for FLEX, limited prescription ranges and outcomes, but it is one of the few innovations to attempt aberration neutral changes to prescription.

The ESCRS had numerous other highlights including the release of Bausch & Lombs' Stellaris phaco system. Indeed, the whole area of micro-incision surgery and small incision IOLs continues to develop apace as evidence grows that doing so may lower postoperative astigmatism and other aberrations still further.

Aspheric IOLs also continue to gain podium time. Techniques of manufacture and design of asphericity may vary, but the quality of outcomes is very consistent.

As the last major European refractive conference of the year closed, there is a sense of 2008 being less active within corporate echelons. High levels of US mergers and acquisitions within the ophthalmic sector must subside over the next 12 months. Private equity's general assault on public markets over the last few years is coming to an end as debt that fuels the deals becomes ever more difficult to find. A period of stability should lead to a further maturation and development of the industry and market. ●

● Mark Korolkiewicz is clinical services director of Ultralase

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