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No phakic IOL is completely safe due to endothelial cell loss; French authorities react
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PARIS — Long-term follow-up of patients implanted with several models of phakic intraocular lenses shows none is completely safe from endothelial cell loss, according to a surgeon speaking at the meeting of the French Society of Ophthalmology. As a result of these and other findings, angle-supported phakic IOLs will no longer be sold and implanted in France.
George Baikoff, MD, reviewed 86 cases in which he explanted phakic IOLs during the last 5 years. Just more than half the explantations — 51% — were due to endothelial cell loss, which occurred several years after implantation, he said.
“I regret having to admit that also the angle-supported phakic IOLs, which I have developed personally over the years, are not devoid of this problem,” Dr. Baikoff said.
“They did extremely well in the first 3 years, during which the endothelial cell count remained perfectly stable. Then, a sudden and dramatic descent started, lowering the endothelial cell count from 2,500 to 1,500. The lowest peak was registered at 60 months,” he said.
The cause of the sudden drop in endothelial cells is not clear. Therefore, Dr. Baikoff recommended caution when performing new phakic IOL implantations and closely monitoring patients already implanted every 6 to 12 months (See related sidebar).
What follows are selected highlights from the SFO meeting. Many of these items originally appeared as live coverage on the OSN SuperSite. See upcoming issues of Ocular Surgery News for expanded coverage of these and other topics from the meeting.
SFO continues to grow in attendance, activities
Year after year, the SFO meeting registers a steady increase in attendance and number of activities, according to its organizers. This year’s meeting was no exception, with participants, including exhibitors, numbering 8,423, 300 more than in 2006. The number of presentations also increased by 12% compared with last year’s meeting.
“The SFO is expanding and increasingly acquiring a central role in responding to the needs of health care providers and the general public,” SFO General Secretary Jean-Paul Renard, MD, said.
“For our colleagues, we have organized more than 100 CME and PPE symposia, wet labs and courses within the meeting this year. More will be available online in the SFO Web site,” Dr. Renard said.
This, like other initiatives of public interest, has been made possible by the official recognition of SFO as a “privileged interlocutor” of the French Ministry of Health.
The open day “A la vue de tous,” traditionally organized in the last day of the meeting, this year gained the patronage of the ministry.
“We open our doors to the public, who can have updated information and ask questions in specific sessions on topics of public interest. This year we proposed children, age-related and environment-related ocular pathologies,” Dr. Renard said.
The same initiative is extended at different dates to 11 other towns in France.
The SFO has also sponsored and organized two campaigns for the detection and prevention of glaucoma and AMD.
“The glaucoma campaign has been ongoing for 3 years. Three specially equipped medical vans travel between 23 towns in France, remaining for 2 whole days in each place. An ophthalmologist and an orthoptist are available there for free eye examinations, specifically aimed at the detection of glaucoma. Last year, more than 8,000 patients were screened,” Dr. Renard explained.
A similar campaign is now starting for AMD, with one van travelling to 11 towns.
“We have multiple goals: prevention, early detection, increasing public awareness and collecting precious epidemiological data for further research,” Dr. Renard said.
AMD was also the topic of the 2007 annual report of the French Society of Ophthalmology. Edited by Giselle Soubrane, MD, the report is an encyclopedic book of more than 600 pages, covering all aspects of this pathology.
“It is highly specialized and rigorously scientific, but also very practical in its approach,” Dr. Renard said.
Societies form new Federation of European Ophthalmology
A supranational European society was founded by representatives of five major European societies of ophthalmology.
 Joseph Colin |
The new Federation of European Ophthalmology (FEOph) currently represents more than 15,000 European ophthalmologists and is aimed at forming a platform to address European issues.
“This society of societies will focus on advocacy, education, guidelines, CME, specialty training and standards in ophthalmology on a European level,” Joseph Colin, MD, OSN Europe/Asia-Pacific Edition Editorial Board Member and president of the SFO, said.
Like Europe itself, the FEOph will be “a synergistic ensemble of different identities” that will encourage an exchange of ideas.
“We are still defining our future programs, but some of the goals we want to pursue have already been outlined,” Dr. Colin said. “In particular, we want to increase the presence of European aspects at national meetings of the various societies. We want to harmonize the programs of national congresses. Finally we want to enable, encourage and support members of the participating societies to attend the meeting of the other partner societies in the status of members of the respective national societies.”
The groups involved in the founding of the new society are the SFO, the German Society of Ophthalmology, the Italian Society of Ophthalmology, the Royal College of Ophthalmologists in the United Kingdom and the Spanish Society of Ophthalmology.
Cataract/Refractive surgery
‘Immobile movement’ technique enhances safety of bimanual MICS
A new “immobile movement” technique for bimanual microincision cataract surgery makes the procedure safer, avoiding often-undetected trauma to the ciliary processes and repercussion on the blood-ocular barrier, according to two surgeons.
 Phillippe Sourdille |
“Damage to the ciliary processes is masked by the iris during surgery,” OSN Editorial Board Member Philippe Sourdille, MD, said. “However, with the help of Miyake-Apple views, we found that elongation of the ciliary processes, and therefore rupture of the ocular barriers, is caused by surgical maneuvers like capsulorrhexis, nucleus fragmentation, nucleus removal and IOL implantation.”
This damage can lead to transient complications or more severe consequences such as cystoid macular edema and retinal detachment.
“Our technique eliminates the risk of these complications entirely,” Dr. Sourdille said.
“Immobile movement” means that all the maneuvers are carried out in the middle of the capsular bag, without moving to the periphery, to avoid traction on the ciliary processes.
“The capsulorrhexis is performed smoothly, without creating folds to avoid zonular traction, and hydrodissection is carried out without rotating the nucleus to avoid traction on the ciliary processes,” Christophe Poirier, MD, said. “During bimanual nucleus fragmentation, we pay a lot of attention to gently separate the fragments without moving the periphery of the capsular bag. For IOL implantation, we place the injector in the center of the capsular bag to have symmetrical, simultaneous unfolding of the haptics in the capsular bag, thus avoiding asymmetrical tractions of the capsular bag.”
Corneal topography differs dramatically before and after epithelial debridement
Debriding the corneal epithelium before performing PRK can dramatically change the anterior corneal topography, according to a study.
Damien Gatinel, MD, and colleagues used the Orbscan II (Bausch & Lomb) to measure corneal topography before and after epithelial debridement in 44 eyes of 25 patients scheduled for PRK. “After de-epithelialization, the topography map, which was performed on Bowman’s layer, showed increased toricity, negative asphericity and irregularity,” Dr. Gatinel said.
The observed effect, which the researchers dubbed EASE (epithelial anterior smoothing effect), may explain the discrepancy between anterior and posterior topographic elevations seen in eyes with early keratoconus, he said.
“It also questions the true interest of topography-guided or wavefront-guided PRK, since the surface that receives the laser ablation is significantly modified in comparison to the surface that was present during the acquisition of the wavefront or topography maps,” Dr. Gatinel noted.
Glaucoma
Study: Glaucoma medication compliance correlates with age, disease severity
Compliance with glaucoma medication use and the quality of drug administration correlate with patient age and disease severity, according to a prospective study of 138 glaucoma patients.
“We asked the patients to fill in a questionnaire concerning the factors that may determine the nonobservance of the treatment schedule. At the same time, we performed visual field examinations and asked the patients to do an instillation of eye drops in exactly the same way they do it at home,” Florent Aptel, MD, said.
The researchers found that 24.2% of patients admitted noncompliance and almost 20% instilled their drops outside of their eye.
Noncompliant patients were mainly younger patients or those with earlier stages of glaucoma who had a tendency to underestimate the severity of their disease. Also, difficulty with drug instillation significantly correlated with older age, poor visual acuity and larger visual field defects, Dr. Aptel said.
“Good vision and stereopsis seem to play a role in the ability to center the eye when instilling drops. Younger patients also did better, possibly because of their better cognitive and sensorial functions,” he said.
Based on the data, the researchers identified two typical patient profiles.
“On the one hand, there are the relatively young patients who have early glaucoma or ocular hypertension and a still have a good quality of life. These patients do their instillation correctly, but have a fairly poor compliance with the treatment, often do not respect hours and intervals between administrations and have periods of discontinuation of the therapy,” Dr. Aptel said.
The second patient profile includes older patients who have more advanced, symptomatic glaucoma that already affects their quality of life, he said.
“They are more respectful of dosages and times, but have difficulties performing [the] instillations correctly and often let all or part of the medication drop outside of the eye,” Dr. Aptel said.
New technologies may help in early glaucoma detection
New functional and structural tests can allow an earlier and more accurate diagnosis of glaucoma, helping prevent the silent progression of undetected glaucomatous damage, according to a specialist.
“We can now go beyond the limitations of standard automated perimetry and use more sensitive, sophisticated technologies,” Elisa Bluwol, MD, of the Hôpital Saint-Antoine, Paris, said.
Dr. Bluwol and colleagues conducted a prospective study including 84 patients with ocular hypertension and 51 patients with preperimetric glaucoma. In all cases, investigators performed Humphrey Matrix frequency doubling technology (FDT), perimetry (Carl Zeiss Meditec), blue-yellow perimetry and retinal nerve fibers analysis with GDx VCC scanning laser perimetry (Carl Zeiss Meditec).
“Blue-yellow perimetry and FDT Matrix allowed an early differentiation between ocular hypertension and preperimetric glaucoma. The association with GDx VCC increased their diagnostic sensitivity. On the other hand, the association of FDT Matrix and GDx seemed to be the most effective in the early diagnosis of ocular hypertension,” Dr. Bluwol said.
Measuring corneal hysteresis using the Reichert Ocular Response Analyzer can also provide useful diagnostic data for the early detection of glaucoma, according to a study presented by N. Fayol, MD, of the Fondation Rothschild, Paris.
“We have compared the corneal hysteresis and corneal pachymetry data of 192 normal eyes, 43 ocular hypertension eyes and 119 glaucoma eyes,” he said. “We have found that corneal hysteresis was significantly different in the three groups. It was lower in the eyes with ocular hypertension and even [lower] in glaucomatous eyes than in normal eyes. Pachymetry data were not equally significant in discriminating between the three groups.”
Retina/Vitreous
Macular translocation still has role in AMD treatment
Although the introduction of VEGF inhibitors has greatly improved the treatment of neovascular AMD, macular translocation surgery remains an important option when medical treatments fail, according to a surgeon.
“Results of this surgery are rewarding and, on the whole, [are] better than those of [photodynamic therapy] without additional anti-angiogenic therapy, as shown by a study,” Cynthia Toth, MD, said.
“However, it cannot be recommended as first-line therapy because, in contrast with medical therapies, [macular translocation] has a fairly high risk of complications,” she said.
Dr. Toth reviewed results of a study involving 64 patients treated with macular translocation with 360· retinotomy. At 4 years follow-up, half of the patients had gained lines of visual acuity. However, 8% of patients experienced retinal detachment, 40% developed cystoid macular edema and 25% experienced a recurrence.
“Recurrence is five times more likely in smokers,” she said, noting that large retinal rotations involve muscle surgery and thus require the joint efforts of two surgeons.
“It is a difficult surgery, where the outcomes are strictly related to experience,” Dr. Toth said. “However, as the surgical technique evolved, surgical time has been greatly reduced. It used to be a 6- to 8-hour operation, and it is now done in less than 2 hours.”
Surgeons are also investigating combining macular translocation and 360° retinotomy with stem cell treatments and neuroprotective therapies, Dr. Toth added.
Gene therapy for ocular pathologies approaches clinical phase
Gene therapy is becoming a realistic treatment option for a number of ocular pathologies, including tumors, glaucoma, AMD, diabetic retinopathy, retinopathy of prematurity, and various congenital forms of retinal and optic nerve degenerations.
“In 2009, we will start the clinical trials in France,” Michel Weber, MD, said.
So far, encouraging results have been achieved with in vitro and in vivo animal studies.
“We found a natural model in dogs with a mutation of the RPE 65 gene, which both in animals and humans is a genetic risk factor for Leber’s disease. Gene replacement by injection of adeno-associated virus (AAV) vectors led to restoration of the retinal function and to consequent visual recovery,” Fabienne Rolling, MD, said.
After gene replacement in one eye, the ability of the dogs to zigzag in between obstacles was tested.
“When we patched the untreated eye, the dogs were able to find their way without problems. When we patched the treated eye, they had enormous difficulties,” Dr. Rolling said.
The best way of delivering the therapy is being evaluated, as optical coherence tomography showed the injection causes localized trauma.
“It’s mandatory that subretinal injection of the therapeutic vector should be performed outside the fovea,” he said.
AAV-mediated gene transfer has also proved effective in the treatment of albinism, according to a study carried out at the Telethon Institute of Genetics and Medicine in Naples.
“Animal testing has demonstrated that gene therapy can trigger the production of melanin, ameliorating retinal function,” Enrico Maria Surace, MD, said.
Encouraging results were also achieved in the treatment of anterior uveitis by gene transfer with non-viral vectors in a study carried out in Paris and presented by Yvonne de Kozak, MD.
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Genetic risk factors of AMD confirmed in European study
Polymorphisms of HTRA1 and PLEKHA1 genes are risk factors for exudative or “wet” AMD in the European population, according to a study carried out at university eye clinics in Créteil, Paris and Lille.
The study presented examined the DNA of 277 patients affected by exudative AMD and 173 age-matched controls. In the AMD group, the presence of the allele T of the HTRA1 gene was double that of the control group (0.50 vs. 0.23). Also, the presence of the allele A of the PLEKHA1 gene was significantly higher in the AMD group than in the control group (0.63 vs. 0.48).
“These results might have important implications in finding new treatment strategies for AMD,” Nicolas Leveziel, MD, said.
The association of these genetic risk factors with other clinical types of AMD may help establish a genotype-phenotype correlation in AMD.
New technology detects reduced concentration of carotenoids in the retina
A new, simple and reliable technology allows the detection of patients at risk of developing AMD due to reduced retinal concentrations of carotenoids, according to a surgeon.
“Raman spectrometry and Flicker technology are widely recognized as reliable means for measuring the concentration of carotenoids in human tissues, but they are complicated and difficult to use. Our system is based on the analysis of RPE [retinal pigment epithelium] reflectivity and has proved reliable at several consecutive time intervals,” Olivier Roche, MD, of Hôpital Necker-Enfants Malades, Paris, said.
The use of this instrument allows the detection of patients at risk of developing AMD many years before the onset of the disease. “We can provide these patients with oral supplementation of lutein, zeaxanthin and meso-zeaxanthin as a preventive measure for AMD,” he said.
The test could be useful in patients with other recognized risk factors, such as family history of AMD, fair complexion, blond hair and pale iris, but even more useful in patients without such recognized risk factors, he said.
Topical anesthesia safer, more comfortable in select 25-gauge vitrectomy cases
Transconjunctival 25-gauge vitrectomy can be performed under topical anesthesia in select cases, according to two studies.
“In the hands of an expert surgeon, this technique allows us to overcome the complications of peribulbar anesthesia, leading to faster and more comfortable postoperative recovery,” O. Rebollo, MD, of Montferrier-sur-Lez, said.
“Topical anesthesia has no complications, saves time and is a particularly interesting option for patients with severe heart problems, patients who are under anticoagulant therapy and highly myopic patients,” said Raphael Adam, MD, of Paris.
Both surgeons reported their clinics’ experiences performing 25-gauge vitrectomy using topical anesthesia containing 2% xylocaine gel. Indications for surgery included epiretinal membrane, intravitreal hemorrhage, vitreomacular traction and macular hole.
The study by Dr. Rebollo and colleagues included data for 55 patients. “All patients did extremely well during surgery,” Dr. Rebollo said.
“A slight and transient pain sensation was experienced at the moment sclerotomies were performed. But a major reduction in [rates] of postoperative problems like hemorrhages, chemosis and conjunctival hyperemia was observed, and this improved greatly the satisfaction and comfort of both patient and surgeon,” he said.
Among the 35 patients included in the study by Dr. Adam and colleagues, pain scores were low and ranged from no pain to only mild pain.
Patients treated for macular holes had the highest pain score, 4 on a scale from 0 to 10, Dr. Adam said.
“The only problem of topical anesthesia is that it does not blockade eye movements. It requires, therefore, some extra caution and a slightly longer learning curve,” he said.
Less vision preserved from PDT, anti-VEGF treatment combination
Combined treatment with VEGF inhibitors and photodynamic therapy can reduce the number of re-treatments needed to control choroidal neovascularization, according to a surgeon. However, anti-VEGF treatment alone appears to yield better visual results, he noted.
Olivier Lebreton, MD, and colleagues in Nantes, France, conducted a study evaluating the effects of secondary treatment with Visudyne (verteporfin, Novartis) photodynamic therapy (PDT) in AMD patients dependent on anti-VEGF treatment.
“Anti-VEGF drugs have been a breakthrough in the treatment of AMD. However, they make the patients become treatment-dependent, as repeated injections are necessary to maintain the benefits of treatment,” Dr. Lebreton said.
The researchers found that combined treatment reduced the number of repeated intravitreal VEGF inhibitor injections needed and, therefore, anti-VEGF drug dependency. However, the combination treatment preserved less vision than anti-VEGF treatment alone, he said.
“By analyzing the results of our patients, we have observed that the final visual outcome is worse in those who were treated with a combination of anti-VEGF [therapy] and PDT than in those who underwent long-term anti-VEGF therapy alone,” he noted.
Secondary treatment with PDT led to scarring of the neovascular lesions. This scarring enhances the effects of anti-VEGF therapy, but worsens the functional prognosis, he said.
“On one hand, there are advantages, [such as] less constraints for the patient, better compliance and savings in money and time to the health services,” he said. “These might be good reasons to adopt this treatment option in the future. However, we must be aware that the effects on preservation of vision might be detrimental.”
New technique safely displaces residual perfluorocarbon liquid
A new technique can effectively prevent the toxic effects of residual perfluorocarbon liquids in the subfoveal region after vitreoretinal surgery.
“It consists of a fairly simple maneuver that displaces the residual PFCL (perfluorocarbon liquid) bubble inferiorly,” Pierre Kahn, MD, said.
The subfoveal retention of PFCL is a rare but severe complication of vitreoretinal surgery that can cause permanent macular damage. The two techniques normally used to resolve the complication involve displacing the bubble with air or puncturing and aspirating the bubble. But both have drawbacks, Dr. Kahn said.
“The first [is] fairly ineffective; the second [is] potentially traumatic,” he said.
The new technique, which Dr. Kahn successfully used in three patients, involves a 39-gauge retinotomy performed under the PFCL bubble, near the inferior temporal vascular arcade. The posterior pole and the inferior periphery of the retina is then detached with the aid of a saline injection, he said.
Patients were immediately placed in the prone position after fluid-air exchange, he noted.
“The bubble of PFCL just dropped in the inferior subretinal periphery without any postoperative complication,” he said, noting that retinas spontaneously reattached 1 day after surgery.
Combination of anti-VEGF and PDT therapy shows efficacy
A combination of bevacizumab intravitreal injection with verteporfin PDT clears the eye from CNV in the majority of patients and decreases the number of treatments, according to the results of a cohort of 100 eyes of 98 patients treated in Creteil, France, under the supervision of Dr. Soubrane and Gabriel Coscas, MD.
All the AMD patients included in the study were either nonresponders to PDT alone or presented some contraindication for PDT, such as anastomosis or RPE detachment. All of the patients received 2 intravitreal injections of 1.25 mg bevacizumab, followed by a PDT session 15 days later. Fluorescein angiography and OCT were performed at 3 months and a second PDT treatment was performed in patients with persistent neovascular activity. In case of enlargement of the neovascular membranes, a second bevacizumab injection was performed.
“The follow-up of patients varied between 3 and 18 months. They had an average of 2.3 bevacizumab injections and 2.3 PDT sessions. Complete reduction of the neovascular activity was obtained in 69% of the patients,” Sam Razavi, MD, said.
“These results are rewarding both in terms of efficacy and in terms of reduction of the number of treatments required, with positive repercussions on the patients’ quality of life,” he said. Similar conclusions were reached by a German study comparing the results of patients treated with anti-VEGF bevacizumab (Avastin, Genentech) intravitreal injection alone and with a combination of bevacizumab injection and PDT.
A total of 130 patients who had not undergone previous treatment for AMD with CNV were included. Of them, 67 received an intravitreal injection of bevacizumab, and 63 received the same injection and PDT.
“Visual acuity results were comparable between the two groups, but the group of patients who underwent anti-VEGF therapy alone had a total number of 120 injections, while the group anti-VEGF plus PDT had a total number of 86 injections,” Martin Rauber, MD, of Sulzbach, Germany, said.
In addition, after one session of the treatment of bevacizumab injection and PDT, 60% of the patients showed complete reabsorption of the macular edema.
“We believe that the association of the two treatments can lead to better long-term results,” Dr. Rauber said.
VEGF inhibitors face regulatory, availability problems in France
Treatments for AMD that target VEGF still face problems with availability, regulatory approval and reimbursement in France, according to a specialist.
Macugen (pegaptanib sodium, OSI/Pfizer) was authorized for sale in France in January 2006, but Lucentis (ranibizumab, Genentech) can only be licensed for temporary use with special importation approval by French authorities. Also, the oncology drug Avastin (bevacizumab, Genentech) has not yet obtained approval for sale. It also has not been approved for treating ocular diseases and therefore is not available in specific preparations for intravitreal use, according to Hélène Nourry, a pharmacist.
Mr. Nourry noted that the Hospital Pharmacy of the Céntre Hôspitalier National d’Ophtalmologie des XV-XX offers syringes with single 0.12 mL doses of bevacizumab.
“This allows us to provide AMD patients with the 1.25-mg dose for intravitreal injection. This off-label use … required the approval by our drug and sterile drug delivery committee … of a specific protocol of indications and inclusion criteria, and the development of a dedicated informed consent,” he said.
However, issues with reimbursement and liability coverage remain unaddressed, he said.
Cornea/External disease
Pterygium remains a concern in North African countries
Despite the many available medical and surgical treatment options, pterygium remains a concern in North Africa due to high prevalence and recurrence rates, according to a surgeon.
Ammar Ailem, MD, and colleagues reviewed data for 200 pterygium cases treated over 20 years in the Algiers area.
Patients averaged 42 years of age and were mostly men. Overall, 97% of cases were unilateral, 93% were primary and 89% evolved “more or less” rapidly, Dr. Ailem said.
Long-term recurrences were observed in 21% of cases, with simple excision associated with the highest recurrence rate, he noted.
Patients treated with conjunctival excision associated with tenonectomy or conjunctival deviation had a slightly lower recurrence rate. However, the best results were seen in patients treated with conjunctival excision associated with either conjunctival autologous graft or amniotic membrane graft, or the use of corticosteroids and light filtration glasses.
“Preoperative and long-term postoperative corticosteroid therapy, associated with regular use of sunglasses, seems to be at present the best preventive measure we can suggest to avoid recurrence,” Dr. Ailem said.
Azithromycin eye drop as effective against trachoma as oral medication
Azithromycin eye drops can be a safer and equally effective alternative to the use of oral azithromycin in the treatment of trachoma, according to a study. The preparation could be particularly beneficial for young children, for whom oral azithromycin is not allowed, the study authors noted.
Isabelle Cochereau, MD, and colleagues conducted a randomized, multicenter study evaluating the efficacy of the azithromycin eye drop T1225 (Laboratoires Thea) in 670 children living in 21 villages in Guinea and six villages in Pakistan. Ages of the children ranged from 1 year to 10 years, and all children had active inflammatory trachoma.
The researchers divided the children into three groups. The first group received the T1225 drop twice daily for 2 days and the second group received the drop for 3 days. The third group received a single 20 mg/kg dose of oral azithromycin, she said.
At 2 months follow-up, the rate of clinical recovery was 93% in the first group and 96% in the second and third groups. Microbiological recovery was 68% in the first group and more than 80% in the second and third groups, Dr. Cochereau said.
“A single eye drop administered twice a day for 3 days is sufficient to treat trachoma and is very well tolerated,” Dr. Cochereau said.
Eliminating blindness caused by trachoma remains a challenge
Despite progress, trachoma remains a major cause of blindness worldwide, particularly in Ghana, where 2.5 million people are at risk of infection and more than 10,000 are at the potentially blinding disease stage, according to a specialist.
“A National Trachoma Control Program was started in the year 2000 by the National Ministry of Health with the partnership of several international organizations, and the year 2010 has been targeted for the elimination of blinding trachoma,” Maria Hagan, MD, said.
She presented the main annual report of the International Organization Against Trachoma.
The National Trachoma Control Program adopted the World Health Organization’s SAFE strategy — surgery, antibiotics, facial cleanliness and environmental improvement. The program provides the mass distribution of azithromycin, donated by Pfizer, free trichiasis surgery, training of local staff for disease detection and treatment, and potable water and sanitary facilities.
However, “trachoma control in a mesoendemic country like Ghana is difficult and requires time and resources,” Dr. Hagan said.
Endemic communities are often far apart and located in hard-to-access regions. Such communities can be further isolated by sporadic ethnic conflicts.
A note from the editors:
To facilitate bringing news to readers rapidly, for OSN SuperSite articles and meeting wrap-up articles, OSN departs from its editorial policy and typically does not send these items out for source corrections.