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SFO described as ‘most international of national meetings’
An effort was made to encourage international participation and to establish stronger relationships with national societies outside France.
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PARIS — Attendance at the meeting of the French Society of Ophthalmology continues to grow, according to meeting organizers. From 3,000 participants in 2001, it reached a total of 7,500 this year, in large part due to increased international participation.
Apart from being “a parameter of health,” according to SFO President Joseph Colin, MD, these numbers show that according to Dr. Colin, the SFO meeting is “the most international of national meetings.”
“As a society, we have always been open to international membership and had special relations with other French speaking countries, particularly of North Africa and of the Middle East. With this year’s meeting we have made a great effort to encourage foreign participation even further and have established new and stronger relationships with other national societies outside France,” he said.
In a session held jointly with the European Society of Ophthalmology, a variety of topics were covered in a series of presentations. Another session, the European Symposium, included presentations and opinions from British, French, German and Italian specialists on the medical treatment of age-related macular degeneration. A Franco-Chilean symposium focused on the treatment of macular edema.
“We have also established new relationships with the American Academy of Ophthalmology, which will lead to new common projects, amongst which is the Franco-American meeting in Paris next year,” Dr. Colin said.
The congress also witnessed the official formation of the International Council of the SFO. This new organization is aimed at increasing foreign membership, facilitating communication between international SFO members and French ophthalmologists and promoting relationships between the SFO and other national societies.
“One or two delegates will be the ambassadors of our society to other countries, and of their country to our society,” Dr. Colin said.
Forty-five countries were represented by members at this first meeting, including countries in Africa, South America, Eastern Europe and the Middle East, he said.
“This council will also have the task of facilitating the sometimes difficult problem of obtaining visas for our members to travel from these countries to France for meetings and other professional purposes,” Dr. Colin said.
Meeting all needs
In order to improve the number and quality of services provided to French ophthalmologists, an increased number of courses, workshops, interactive wet labs and surgical simulations were featured at this year’s meeting.
“The law that submits all medical practices to evaluation and all doctors to the obligation of continuous medical education was enforced here in France at the beginning of 2006. To explain the details of these new regulations to our colleagues, we have organized a forum attended by several hundred people,” Dr. Colin said.
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Image: Mullin, DW, OSN |
An increased number of sponsored symposia also demonstrated that the SFO is intensifying its relationships with industry.
At well-attended industry-sponsored lunch symposia, physicians had the opportunity to combine science and pleasure in a friendly, informal atmosphere.
Also this year, the open day “A la Vue du Tous” (“In View for Everyone”) offered the general public the opportunity to ask questions of physicians. Specialists were made available to provide information on this year’s topics: refractive surgery, low vision, glaucoma and dry eye.
“As a national society we are more and more convinced that we have a mission in public health care, information and prevention,” Dr. Colin said.
The same types of public conferences were organized 2 weeks before the meeting in nine other cities in France.
“Patients who are informed are better and more effectively cured than patients who don’t know anything about their disease. In their daily practice, doctors don’t always have the time to explain everything to their patients, and on the other hand patients don’t dare ask all the questions they have in mind,” he added.
The media, Dr. Colin said, often provide limited, distorted or biased information that does not reflect “real life” medical practice and progress.
This year’s event was widely publicized and well attended.
2006 report: the lacrimal system
The lacrimal apparatus was the topic of the 2006 annual report of the SFO, a publication coordinated this year by Alain Ducasse, MD, of Rheims. Presentations by some of the contributing authors summarized the most important chapters of the report, concerning the anatomy, physiology, exploration, pathology and treatment of the lacrimal system.
“In the last few years there have been remarkable advances in our subspecialty ,” Dr. Ducasse said. “Endoscopy and other methods of imaging have immensely improved our diagnostic and treatment capabilities. Surgical techniques like both internal and external dacryocystorhinostomy have been optimized and have achieved a high success rate. New and further improvements have been implemented by the use of lasers, mitomycin-C and botulinum toxin.”
He added that future developments will come from increased knowledge of the causes of lacrimal system disorders; from constant improvements in optic technology, lasers and drills; and from the increasing miniaturization of surgical instrumentation.
“Endoscopy, I am sure, will have a primary role in both diagnosis and therapy,” he said.
The prevalence and causes of excessive lacrimation, a common symptom of lacrimal system disorders, were investigated in a prospective study carried out by Drs. Ducasse and Jean-Luc George in the two centers of Rheims and Nancy. The study included 752 patients seen over a period of 2 years. In one out of three patients the symptom was bilateral.
“We observed a marked female prevalence. In our series, 60% were women. As far as age is concerned, excessive lacrimation appears to be most frequent after the age of 65, but also between 0 and 10 years. The prevalence of children of less than 10 years was between 9% and 20% in our series,” Dr. Ducasse said.
Congenital lacrimal duct obstruction, present in 5% to 20% of pediatric patients, was found to be the most frequent cause of excessive lacrimation in children. In adults, the symptom may or may not be correlated with some form of stenosis of the nasolacrimal duct, he said.
Treating young and old
A randomized prospective study carried out in Lyon demonstrated that nasolacrimal probing can be a good option in infants with congenital nasolacrimal duct obstruction.
This pathology is frequently encountered in pediatric ophthalmology, but so far there is no uniform approach to therapy. Many centers still prefer the medical treatment of local secondary infections such as conjunctivitis, waiting for the spontaneous resolution of the pathology.
“Our study was an attempt to develop a common attitude based on statistics,” said Jean Marc Ruban, MD, of Lyon.
The study was conducted in two groups of infants aged between 3 and 12 months. One of the groups was kept under medical surveillance and treated in case of infection, while the second group underwent probing.
Results demonstrated that between the age of 3 and 8 months there was no statistically significant difference between the two methods with a comparable rate of success (86%). However, probing was demonstrated to have a more rapid healing effect.
“With probing, the delay of healing was very short, between 10 and 20 days, while medical treatment took more than 2 months,” Dr. Ruban said.
On the other hand, the rate of spontaneous healing decreased constantly with age. After the age of 8 months, less than 8% of children experienced spontaneous healing.
“Around the age of 8 months, if not earlier, probing should be routinely offered to these patients without any further delay,” he concluded.
In older patients, bicanaliculo-nasal intubation is probably the best option for treating lacrimal system obstructions, according to C. Zahid, MD, of Rabat, Morocco. However, excessive cicatrization may cause this technique to fail.
“The use of mitocycin-C can effectively inhibit fibroblastic proliferation and scarring,” he said.
In a study, two groups of 12 patients aged between 50 and 65 years underwent bicanaliculo-nasal intubation. Mitomycin-C in a concentration of 0.2 mg/mL was applied intraoperatively for 15 to 30 minutes in only one group. Patients were seen over a period of 3 years, and the outcome of surgery was evaluated on the basis of subjective signs, such as lacrimation, and objective examinations, such as fluorescein dye test and lacrimal system irrigation.
“In the group treated with mitomycin-C, surgery was successful in seven cases, while a failure of the intubation was found in nine patients of the other group,” Dr. Zahid said.
He concluded that, although evaluation of a larger series of patients and a longer follow up is necessary to achieve more stable conclusions, the use of mitomycin-C seems to improve the results of the technique.
Internal and external DCR
Endoscopic transcanalicular surgery using the new Endognost (Schwind Co.) instrument with flexible titanium probe has a high rate of success, according to Holger Busse, of Münster, Germany.
The instrument, which can be combined with a laser or with a microdrill, has an image transmission of 6,000 pixels and an illumination range of more than 4 cm.
“We used it in combination with a Nd:YAG laser in 53 patients undergoing intubation surgery and obtained an overall recanalization in 75% of the cases,” Dr. Busse said.
Transcanalicular endoscopic DCR can also be performed by using more powerful lasers, also with a good success rate, he said.
“However, more powerful lasers cause damage to the surrounding tissues, and the technique needs therefore further developments,” he said.
Dr. Busse said he also routinely uses the Endognost system as an exploration and diagnostic tool, in addition to its role as a surgical aid.
“Based on what you see, you can immediately decide what’s the best treatment option,” he said.
“If you have sufficient volume of the lacrimal sac, you perform endoscopy-guided intubation using microdrill or laser. If you see signs of mucosal inflammation, it is better to do a DCR. If you find mucosal folds, you can again use the laser or the microdrill combined with intubation. If it’s bone, you need the microdrill, and if you find a tumor, [you can] stop and do a surgical exploration.”
In case of stenosis, he added, the exact localization is crucial for deciding the appropriate surgical method.
“If you find a stenosis of the canaliculum and it is punctiform, you can try with the laser, although results are not as good as we thought. If it is in the common punctum, you can use the laser in combination with intubation or microsurgical reconstruction, depending on the quality of the stenosis. If you are in the lacrimal sac, use the laser or the microdrill in combination with intubation or perform DCR,” Dr. Busse said.
In his clinic in Münster, more then 400 cases a year are treated, and the endoscopic method is now used routinely, he said.
“Advantages are good results, 75% to 80% recanalization and a minimum of trauma. In case of re-stenosis, all other surgical procedures are possible,” he said.
The more classical, external DCR procedure can be performed with a surgical technique that guarantees efficacy and stability of the results and almost no visible scars, as shown by Geoffrey Rose, MD, of London.
He explained that the role of DCR is to convert the lacrimal system, which is a three-compartment model (lacrimal lake, lacrimal sac and nasal space), to a two-compartment model (the lacrimal lake and the nasal space). In this way, the surgeon can achieve 100% cure of volume symptoms.
One of the causes of failure in DCR is that “rhinostomy is made far too small, so that you end up with a residual fluid in the second compartment. In addition, small rhinostomies undergo fibrosis,” he said.
To obtain good results, the lacrimal sac has to be “wide opened to the nose, like a book, right from its very fundus, down to the nasolacrimal duct,” he said.
To avoid scars, Dr. Rose performs a straight incision of at least 1 cm in front of the medial canthal tendon, on the flat side of the nose, using a surgical technique that avoids cutting muscles, which produces a minimum of bleeding. He reaches the fundus of the lacrimal sac and, by progressively removing bone, starting from the anterior lacrimal crest, he performs an anterior ethmoidectomy.
“This last maneuver allows you to open the lacrimal sac and the nasal mucosa like a book, down to the fundus,” he said. Careful internal and external suturing will leave patients with almost no sign of the incision within 10 days, he said.
Bevacizumab generates increased interest, expectations
A proliferation of data and recently published papers are confirming both the safety and efficacy of intravitreal bevacizumab use for the treatment of neovascular age-related macular degeneration, according to a symposium on AMD.
“We are currently in the stage of collecting all the clinical data, and hopefully a multicenter randomized prospective clinical study will soon be started to compare Avastin (bevacizumab, Genentech) with the standards of care,” said Christos Haritoglou, MD.
Dr. Haritoglou said the intravitreal version of the cancer drug is “safe in all concentrations that have been used, and it does not penetrate the retina.” Some studies have shown that its efficacy in reducing retinal thickness and leakage plays a role in halting the progression of visual loss.
“Positive results are reliable, but the problem is that the use in ophthalmology is still an off-label use,” Dr. Haritoglou said.
He said ophthalmologists have “great expectations” for the drug because it is much less expensive than the alternatives that are currently available. “This could give new hope to patients who suffer so much,” he said.
Aside from neovascular AMD, the drug has also been studied for the treatment of proliferative diabetic retinopathy, neovascular glaucoma and neovascularization of the iris.
“There are potentially many fields of application, and we need further investigations to find out which patients can benefit more from the use of this drug,” Dr. Haritoglou said.
Recent views on glaucoma
Recent studies update views on glaucoma treatment in Europe
Recent clinical trials have “deeply modified” some older views on the treatment of glaucoma, said Norbert Pfeiffer, MD, speaking here at the meeting.
“Probably the most important discovery is that in advanced glaucoma or in progressing glaucoma, IOP needs to be far lower than previously assumed, namely around 12 mm Hg, to keep a stable eye,” he said.
Physicians will often prescribe more than one medication to achieve such low IOP levels, leading to potential patient compliance problems, Dr. Pfeiffer said.
“We should be aware that at least 50% of our patients have poor compliance with the treatment when they have to use more than one medication several times a day,” Dr. Pfeiffer said.
Prescribing fixed combination drugs would probably improve patient compliance, as well as treatment efficacy, for most of these patients, he said.
Recent studies have also demonstrated that prostaglandins have several mechanisms of action, he said. Prostaglandins not only decrease IOP by increasing uveoscleral outflow but also may affect the increased levels of endothelin in patients with glaucoma.
“Endothelin, which constricts the trabecular meshwork and decreases the outflow, is antagonized by at least some of the prostaglandins,” Dr. Pfeiffer said.
The European Glaucoma Society has summarized key findings and treatment guidelines for glaucoma. The group translated the guidelines into several languages for distribution to more than 70,000 ophthalmologists throughout Europe and beyond, Dr. Pfeiffer said.
“The executive committee of the EGS hopes that this will unify and strengthen glaucoma treatment in Europe,” Dr. Pfeiffer. “According to recent statistics, 74% of European ophthalmologists are aware of the EGS guidelines, and 61% follow them in their daily practice.”
Topical anesthesia a valid alternative in deep sclerectomy
“In association with small doses of sedatives, [topical anesthesia] is almost as effective as peribulbar anesthesia throughout deep sclerectomy surgery,” according to results of a study. “Patients only complain of a faint sensation of pain, which is compensated by the benefits of a more rapid and comfortable postoperative recovery,” said Vanessa Maria Paletta Guedes, MD.
The painkilling effects of topical anesthesia (tetracaine 2% plus intravenous propofol) were evaluated in 36 patients undergoing deep sclerectomy 15 minutes and 24 hours after surgery and compared to the effects of peribulbar anesthesia (lidocaine 2% plus bubivacaine 0.75%) in a group of 33 patients at the same time intervals. Evaluation of pain was done according to the Mann-Whitney test.
“The two groups reported a different perception of pain 15 minutes after surgery. Topical anesthesia was undoubtedly less effective, but the level of subjective pain reported by the patient was only very mild in all the cases. The evaluation made one day after surgery didn’t show any significant difference between the two groups,” Dr. Paletta Guedes said.
Surveys on glaucoma
A survey carried out in France estimated that 1.2 million people aged 40 years or older are medically treated for glaucoma or ocular hypertension with pressure-lowering drugs.
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Image: Mullin, DW, OSN |
“This study has given us the opportunity to draw some interesting conclusions,” said Alain Bron, MD, of Dijon, France.
Demographically, a higher prevalence was reported in relation with areas of higher population density, which corresponds to a higher density of medical services.
“There are areas in France that are still not properly covered by the medical services that are needed for appropriate screening and early diagnosis of glaucoma within the general population,” Dr. Bron said.
Variations in prevalence were also seen in relation with educational and social levels, he said.
From the point of view of treatment, the population of patients using topical medications was almost equally divided between monotherapy (29%), therapy with two drops (36%) and therapy with three or more drops (33%).
Although beta-blockers are still the most commonly prescribed drugs (60%), prostaglandins are beginning to be widely used as a therapy (45%), indicating that medical practices are evolving according to the indications of recent studies.
The survey also revealed that a high percentage of patients (39%) show poor compliance with treatment. Compliance tends to be inversely related to the number of daily drops needed by the patient.
“The more drops a patient has to use, the less compliant he or she tends to become toward the treatment. Younger patients also tend to be more careless and irregular than older patients. Sixty-seven percent of patients who admit to being irregular with their medications are between the ages of 40 and 49,” Dr. Bron said.
Compliance, he admitted, is a major problem that glaucoma specialists everywhere, not only in France, must take into consideration.
Visual impairment caused by glaucoma has a social cost of approximately €5,000 per year for each affected patient in both France and Denmark, according to a socioeconomic study on glaucoma and blindness in Europe, he said.
“With the aging of the population, the prevalence of glaucoma is going to increase in future years. The aim of this study, which is going to be extended to other countries in Europe, is to make a balance between the cost of blindness or low vision related to glaucoma and the cost of prevention and therapy,” Dr. Bron said.
The medical costs involved in glaucoma-related blindness are negligible (9%), because “medical treatment and examinations are of little benefit to the patient at this stage,” Dr. Bron noted. A slightly higher percentage (14%) is taken up by low-vision aids, but the majority of costs, up to 73% of the total, are related to house help for all daily tasks such as cooking, shopping and cleaning.
“Most of these expenses are covered, both in France and Denmark, by the national social security system. Partly, they can be provided by private insurances,” Dr. Bron said.
The economic burden that glaucoma-related blindness imposes on governments should become one further reason to invest resources in prevention, early diagnosis and treatment, he said. As Dr. Bron pointed out, this policy would save a considerable amount of public money in future years throughout Europe.
Better prognosis in pediatric surgery
Although retinal detachment in children remains a severe pathology, recent advances in surgical techniques allow remarkably better anatomical and functional results, according to more than one surgeon speaking here.
A retrospective study of 99 eyes of 88 patients aged between 2 and 16 years, treated for retinal detachment between January 2000 and September 2005, showed a high rate of success.
“Final success, after one or more operations, was obtained in 81% of the cases. Visual acuity was better than 20/400 in 55% of the cases,” said Baptiste Dufay-Dupar, MD, of Paris.
In his case series, the main cause of retinal detachment was trauma (48%), followed by myopia (21%). Patients were predominantly boys (68%) and in two-thirds of the cases the diagnosis was delayed by more than 1 month.
“Delayed diagnosis and vitreoretinal proliferation still account for a number of failures in the treatment of this pathology in young patients,” Dr. Dufay said.
A shorter series of 24 eyes of 22 patients with a mean age of 9 years, treated for retinal detachment between January 2004 and May 2005 at the Eye Clinic of Algiers, Algeria, was presented by M. Djabour, MD. A wider variety of causes were reported among these patients, including trauma (33.3%), retinoblastoma (16.6%), myopia (8.3%), aphakia (8.3%), retinopathy of prematurity (4%) and other causes.
Dr. Djabour said he was satisfied with the results. Reattachment was obtained in 11 cases, and visual acuity ranged from count fingers to 20/60 (in one eye).
“The progress of vitreoretinal surgery in recent years gives us the opportunity to save eyes that would have been lost in the past,” Dr. Djabour said.
Successful corneal grafting can be obtained in infants provided that surgeons take into account the specific intraoperative and postoperative requirements connected with the anatomy and physiology of these young eyes, according to Pascal Dureau, MD, of Paris.
“Infants have smaller eyes, lower scleral rigidity and a higher vitreous pressure. These characteristics make it necessary to adopt a surgical technique that differs from that used in adults’ eyes,” he said.
A Flieringa ring is fixed to the epi-sclera and suspended by a blepharostat to lift the globe and reduce vitreous pressure. A disposable trephine is used because the Hanna trephine is unsuitable for small eyes, he said.
“The donor graft must be larger by about 0.5 mm than the recipient bed to facilitate the formation of the anterior chamber and to progressively adapt to the growing globe,” Dr. Dureau said.
Single sutures must be applied to allow early and, in some cases, partial and rapid removal.
Postoperative treatment requires the use of local corticosteroids for 1 year and 2% cyclosporin drops four times daily.
“The use of cyclosporin seems to minimize the risk of rejection and improve the prognosis of this surgery,” Dr. Dureau said.
Amblyopia, he said, remains a problem with young patients and plays a major role in the functional results of this surgery.
The results of penetrating keratoplasty in 19 eyes of 18 patients whose median age was 17 years were reported.
“We obtained a clear corneal graft in 13 cases. Rejection occurred in six cases and retinal detachment in three cases. Both of these complications were more frequent in eyes operated for ocular injuries. Cataract developed in four cases due to therapy with corticosteroids, Dr. Dureau said.
Although functional results are difficult to evaluate in very young children, he estimated that postoperative visual acuities ranged from 0 to 20/30.
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- Michela Cimberle is an OSN Correspondent based in Treviso, Italy, who covers all aspects of ophthalmology. She focuses geographically on Europe.