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Consultant ophthalmologist Sheraz Daya introduced the event at the clinic, where patients are treated for all types of anterior eye conditions. Centre for Sight currently has the UK's only Victus femtosecond laser which is used for laser refractive, corneal transplantation and also precision cataract surgery. The centre also uses the Zyoptix laser platform used to perform wavefront laser surgery in conjunction with its Intralase femtosecond laser.
In his introduction, Daya discussed the crisis on the horizon for UK eye care as huge numbers of baby-boomers reach the age when cataract surgery, diabetic conditions, age-related macular degeneration and glaucoma, among other conditions all become a reality. He felt that it was important to develop long-term and sustainable relationships between optometrists and medical clinics so that roles in shared care could be designated with good communication between the two sectors.
Cornea update
Corneal transplantation was pioneered at the nearby Queen Victoria Hospital, East Grinstead, where the oldest (1952) eye bank in the UK is housed. The evolution of techniques dating back to the first successful corneal transplant performed by Zirm in 1905 was described by Daya. Thankfully, techniques have moved on with the most exciting changes being in the last 15 years.
The concept of 'selective corneal transplantation' was discussed in detail. Deep anterior lamellar grafts using the femtosecond laser are effective, particularly in cases of keratoconus. The advantage of this technique is a much lower rejection rate than other solutions. Descemet's stripping automated endothelial keratoplasty (DSAEK) replaces the inner layers of the cornea and has revolutionised the care of patients with Fuchs' endothelial dystrophy, where recovery is quite rapid and there is a low rejection rate. Limbal stem cells grown in sheets in a laboratory can be transplanted to eyes damaged by burns or chemicals and some very impressive case studies were shown.
Keratoconus
Signs and symptoms of keratoconus were discussed, specifically those that could be seen on slit-lamp examination. In Daya's opinion, corneal topography is essential in optometric practices to identify keratoconus early. With corneal cross linking (CXL) progression of keratoconus can be reliably arrested. New technologies for measuring keratoconus were also discussed, including the Corvis ST from Oculus which uses Scheimpflug video imaging to measure the deformation of the cornea in response to a puff of air.
Crosslinking is used to strengthen the collagen fibres and uses riboflavin soaked into the cornea with UV light exposed to the cornea. Centre for Sight has developed a special instrument (Daya Epithelial Disruptor) to make holes in the epithelium of the cornea to allow the riboflavin to penetrate the cornea. Previously, patients had to have the whole epithelium removed, making recovery longer and more painful. The aim of the treatment is to stop progression of keratoconus or ectasia following laser treatment. Large numbers of patients have been treated at the clinic since 2005 with the youngest being six years old. Other techniques discussed include intracorneal rings, implantable lenses and femtosecond deep anterior lamellar keratoplasty.
Meibomian gland technologies
The epidemic of meibomian gland dysfunction, possibly caused by a lack of pure omega-3 triglyceride in our diet, was next under discussion. Replacement with a re-engineered re-esterified omega-3 is something that Daya believes will revolutionise the condition in the future. 'Omega eye' is one such product that is awaiting approval in Europe.
He also talked about a new therapy called Lipiflow. Objective tear analysis is performed using the Lipiview system. This measures the lipid layer in the tear film. Meibomian glands are also analysed objectively and if felt to be suitable, the Lipiflow treatment can be applied. In a 12-minute treatment the meibomian glands can be cleared out using a warm, pulsing pad applied to the eyelid. The system can be equivalent to 13 months of conventional therapy and is used to boost those with meibomian gland dysfunction.
Live surgery
The main highlight of the day was live surgery broadcast using two camera views to the auditorium. Three patients were treated. The first was a bilateral Zyoptix aspheric wavefront Intralasik. The 38-year-old woman had a R -1.25/L -1.50 Rx treated with a 6.5mm zone. The second case was a 51-year-old woman who had hyperopic Lasik 10 years ago and was now undergoing a refractive lens exchange to her second eye with the Finevision Trifocal implant. The Victus femtosecond laser was used to create the capsulotomy.
Optometrists were able to view live OCT of the cornea and lens as the treatment was being planned and in real time as the laser was used. The femtosecond process appeared gentler on the eye with a phenomenal level of accuracy. It seemed a much safer procedure than conventional cataract surgery.
The final case was a Visian ICL, implanted into a patient from Ireland who had had a corneal transplant and had been left with a high level of astigmatism. The lens implanted was a +0.50/-6.00 x 174 and it was very interesting to see the lens rotated behind the iris as you would a cylinder in a trial frame. ?
? Emma Deighan is head of clinical education, Birmingham Optical Group