What’s ahead in 2008
A wish-list of new technologies for 2008

A panoply of innovative products await in the upcoming year

Pixelate optics will make it possible to attain a change in refraction of up to 4 D in a standard IOL with the apparatus
Source: I. Howard Fine, M.D.


More than 80% of patients enjoy a gain of three or more lines of vision with the implantable miniature telescope
Source: Mark Packer, M.D.

It’s that time of year again and practitioners around the country are waking up to find their stockings brimming with bright shiny new ophthalmic possibilities. We asked some leading practitioners to fill us in on some of the hottest new technology for the upcoming year.

Finding sparkling new implants

There’s some fantastic new IOL technology in the wings, believes I. Howard Fine, M.D., clinical professor, Casey Eye Institute, Oregon Health & Science University, Portland. One innovative possibility is the accommodative NuLens (NuLens, Herzeliya, Israel). “This is made of a compressible polymer between two PMMA plates,” Dr. Fine said. “The anterior plate has an aperture and with accommodative effort the polymer can be compressed and will bulge through the opening in the anterior plate.” This has been known to make a rather steep curve. “In the earliest data on humans they got at least 10 D of amplitude of accommodation,” Dr. Fine said.
He also pegs “pixelate optics” as another fascinating new technology. “A pixelated apparatus, such as a thin plate, can be inserted into the center of a standard IOL,” Dr. Fine said.“ These pixelated optics can undergo a change in index of refraction of up to 4 D.” With this electro-optical device some pixels can be dedicated to recognizing contrast, as they are in the auto focus mode with a digital camera. A capsular tension ring could be used to power the pixelated optic lens and could be charged from outside of the eye once a year, he believes.
Wavefront technology is also going to be added to the ReSTOR lens (Alcon, Fort Worth, Texas), believes Dr. Fine. “I don’t think that it’s too big a reach to anticipate multifocal lenses that will have combinations of toricity, wavefront technology, and multifocality,” he said.
Another implant on the horizon is the implantable miniature telescope (VisionCare, Saratoga, Calif.) for patients with wet AMD or geographic atrophy. “That was stalled out because of a bad panel decision at the FDA [Food and Drug Administration], because of endothelial cell loss,” noted Mark Packer, M.D., clinical associate professor, Casey Eye Institute, Oregon Health & Science University. The device, which requires a 10 mm incision to insert, is a large one. While there is endothelial cell loss with insertion it is not ongoing. “The results from the FDA study show that 67% of the subjects got three or more lines of improvement with the device,” Dr. Packer said.

Unwrapping new phaco boxes

New phaco machines in the offing include the Stellaris (Bausch & Lomb, Rochester, N.Y.), and the Signature (Advanced Medical Optics, Santa Ana, Calif.). “One of the great advantages of the new Signature will be its dual pump system,” Dr. Fine said. “You can choose to use either a Venturi or a peristaltic pump.” The machine will also have something akin to torsional phaco, dubbed elliptical, which will reduce power and vacuum needed to remove nuclear material.

Seeing intriguing imaging possibilities

A new 3-dimensional video system being developed by a company known as TrueVision, will eventually replace slit-lamps and operating microscopes, believes Eric D. Donnenfeld, M.D., Co-Chair, External Disease/Cornea, Manhattan Ear & Eye Institute, Rockville Centre, N.Y. Among its assets are outstanding resolution and much greater depth of field. “It’s going to allow surgeons to perform telemedicine,” Dr. Donnenfeld said. “You’ll be able to go down and teach anywhere in the world by looking at video images online.”
Also likely to become available in 2008 is WaveTec’s (Los Angeles) new intraoperative aberrometer, which will give real-time results during the procedure and enable surgeons to make lens power adjustments on the fly. “It will allow us to do cataract surgery and then do an aberrometry during the surgery to look at residual refractive error so that we can for example extend the limbal relaxing incisions, or exchange an intraocular lens for a better one, or rotate a toric lens during the surgery,” Dr. Donnenfeld said. “I think that it will be most effective for patients who have had previous refractive surgery such as LASIK or PRK, for which it can often be difficult to predict the refractive results.”
For glaucoma, a change in software for the RetCam (Clarity Medical Systems, Pleasanton, Calif.) will expand the use well beyond retinopathy of prematurity, according to Richard A. Lewis, M.D., a glaucoma consultant and in private practice in Sacramento, Calif., “A change in software allows you to take pictures in the anterior part of the eye in all patients,” he said. “So, you can take pictures of the angles instead of doing a gonioscopy and you can document anterior segment problems.” The device has very little learning curve, with no specialized technician needed, he points out.
Also coming out in 2008 is a device currently dubbed P2 (Clarity Medical Systems). “It’s a fascinating device that gives three dimensional images of both the anterior and posterior segments of the eye,” Dr. Lewis said. “It takes 40 milliseconds to take an anterior segment or posterior segment picture, which is then projected onto your computer screen.” A technician could run the test in one building and then send it directly to the practitioner’s desktop in another location.

Fresh new glaucoma angles

Drug delivery for glaucoma medication may soon get easier. Work is currently being done on a new punctal plug that would administer the medication over a 90 day period. Dr. Lewis sees this punctal plug as likely going into clinical trials by the first quarter of 2008. “They’ll put glaucoma drug in this punctal plug and it will release slowly for three months and that way patients won’t have to take their drops everyday,” he said. “I think that it’s a great use of technology—it’s simple, elegant, and it will avoid so many problems.”
Ike K. Ahmed, M.D., assistant professor at the University of Toronto, believes that another hot area in 2008 will be the drive towards bleb-less alternatives to trabeculectomy. “There’s further technology that is going to be coming out in the next year or so that is designed to enhance aqueous outflow in a physiologic manner,” Dr. Ahmed said. “Procedures include canaloplasty, the Schlemm’s canal stent, and superchoroidal drainage devices.”
The canaloplasty technique, which is a dilation procedure of Schlemm’s canal, is being advanced by iScience Interventional (Menlo Park, Calif.). Canaloplasty is essentially dilation of the canal with placement of a tension suture in the canal to keep it open to maintain patency and circumferential flow,” Dr. Ahmed said. He dubs it as analogous to angioplasty with a stent for heart surgery.
Meanwhile, with the Schlemm’s canal stent, known as Glaukos (Laguna Hills, Calif.), practitioners would place the microscopic device through the eye into the canal to bypass the inner wall there. “We are now bypassing the inner wall which is where the pathology is in glaucoma and creating a direct communication between the anterior chamber and the canal,” Dr. Ahmed said.
The third type device, known as superchoroidal shunts are intended to enhance aqueous outflow by increasing uveoscleral drainage. “It is a bit of a mysterious and not well understood pathway, but yet we know that it’s potentially very potent.”

Note: Dr. Fine has financial interests with Advanced Medical Optics (AMO, Santa Ana, Calif.), Bausch & Lomb (Rochester, N.Y.), Carl Zeiss (Dublin, Dalif.), and iScience Interventional (Menlo Park, Calif.). Dr. Donnenfeld has financial interests with AMO, Alcon (Fort Worth, Texas), and Bausch & Lomb. Dr. Ahmed has a financial interest with Carl Zeiss, Glaukos (Laguna Hills, Calif.), iScience Interventional, and Solx (Waltham, Mass.). Dr. Lewis has financial interests with Clarity (Pleasanton, Calif.), iScience Interventional, and Santen (Napa, Calif.), among others. Dr. Packer has financial interests with Carl Zeiss, Visiogen (Irvine, Calif.), VisionCare (Saratoga, Calif.), and WaveTec (Los Angeles), among others.

Contact Information

Ahmed: 905-820-6789, ike.ahmed@utoronto.ca
Donnenfeld: 516-766-2519, eddoph@aol.com
Fine: 541-687-2110, hfine@finemd.com
Lewis: 916-649-1515, rlewiseyemd@yahoo.com
Packer: 541-687-2110, mpacker@finemd.com