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PHACO ERSATZ  HOW AND WHY DID IT START ?  WHERE DO WE GO?  FRANK JOSEPH GOES   Antwerp-Belgium. ESCRS 2011.

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Presentation on theme: "PHACO ERSATZ  HOW AND WHY DID IT START ?  WHERE DO WE GO?  FRANK JOSEPH GOES   Antwerp-Belgium. ESCRS 2011."— Presentation transcript:

1 PHACO ERSATZ  HOW AND WHY DID IT START ?  WHERE DO WE GO?  FRANK JOSEPH GOES   Antwerp-Belgium. ESCRS 2011

2 PHACO ERSATZ WHAT DOES IT MEAN????? REPLACING T HE NATURAL LENS OF A 60 YEARS OLD BY AN ARTIFICIAL LENS PERFORMING LIKE A 2O YEARS OLD ESCRS 2011

3 WHY SHOULD WE REPLACE THE NATURAL LENS ? ACCOMODATION AGE ESCRS 2011

4 WHAT IS ACCOMODATION ???  Described by HELMHOLTZ1853.  Accommodation is the process by which the eye changes its refractive power to bring objects of regard at different distances into focus.  During accomodation contraction of the ciliary muscle releases the at rest zonular tension around the lens equator and the lens increases in axial thickness and in anterior and posterior diameter. ESCRS 2011

5  The principle of accommodation was discovered in the 17 th century by Scheiner.  The theories for presbyopia are generally addressing the age changes in the lens, the lens capsule and/or within the lens support structures. Recent studies have shown that the stiffness of the lens substance increases with age by a factor 1000 to over a lifetime. ESCRS 2011

6 . Loss of accommodative amplitude with age. Predicted by lens stiffness changes alone, compared to measured objective accommodative amplitude ESCRS 2011

7 WITH AGE THE LENS CHANGES  the central thickness of the (disaccommodated) lens increases.  the equatorial diameter of the (disaccommodated)lens does not change  the surface curvatures of the (disaccommodated) lens increase  the lens matrix loses its elasticity  the mechanical properties of the capsular bag change  the thickness of the lens capsule changes. The thickness of the anterior capsule increases  the thickness of the posterior pole shows no change with age and the posterior peripheral thickness decreases  the elasticity of the zonular fibers does not change  there is no change in the number of zonular fibers  the insertion points of the anterior zonular fibers stay fixed in relation to the lens center, but shift in reference to the lens equator  HENK WEEBER ESCRS 2011

8  /Region Extrapolated Prevalence Population Estimated Used Presbyopia in North America (Extrapolated Statistics) USA 26,428, ,655,405 1 Canada 2,925,708 WARNING! (Details) 32,507,874 2 Mexico 9,446,363 WARNING! (Details) 104,959,594 2 Presbyopia in Central America (Extrapolated Statistics) Belize 24,565 WARNING! (Details) 272,945 2 Guatemala 1,285,253 WARNING! (Details) 14,280,596 2 Nicaragua 482,378 WARNING! (Details) 5,359,759 2 Presbyopia in Caribbean (Extrapolated Statistics) Puerto Rico 350,816 WARNING! (Details) 3,897,960 2 Presbyopia in South America (Extrapolated Statistics) Brazil 16,569,099 WARNING! (Details) 184,101,109 2 Chile 1,424,156 WARNING! (Details) 15,823,957 2 Colombia 3,807,969 WARNING! (Details) 42,310,775 2 Paraguay 557,223 WARNING! (Details) 6,191,368 2 Peru 2,478,987 WARNING! (Details) 27,544,305 2 Venezuela 2,251,564 WARNING! (Details) 25,017,387 2 Presbyopia in Northern Europe (Extrapolated Statistics) Denmark 487,205 WARNING! (Details) 5,413,392 2 Finland 469,306 WARNING! (Details) 5,214,512 2 Iceland 26,456 WARNING! (Details) 293,966 2 Sweden 808,776 WARNING! (Details) 8,986,400 2 Presbyopia in Western Europe (Extrapolated Statistics) Britain (United Kingdom) 5,424,363 WARNING! (Details) 60,270,708 for UK 2 Belgium 931,344 WARNING! (Details) 10,348,276 2 France 5,438,179 WARNING! (Details) 60,424,213 2 Ireland 357,260 WARNING! (Details) 3,969,558 2 Luxembourg 41,642 WARNING! (Details) 462,690 2 Monaco 2,904 WARNING! (Details) 32,270 2 Netherlands (Holland) 1,468,637 WARNING! (Details) 16,318,199 2 United Kingdom 5,424,363 WARNING! (Details) 60,270,708 2 Wales 262,620 WARNING! (Details) 2,918,000 2 Presbyopia in Central Europe (Extrapolated Statistics) Austria 735,728 WARNING! (Details) 8,174,762 2 Czech Republic 112,156 WARNING! (Details) 1,0246,178 2 Germany 7,418,214 WARNING! (Details) 82,424,609 2 Hungary 902,913 WARNING! (Details) 10,032,375 2 Liechtenstein 3,009 WARNING! (Details) 33,436 2 Poland 3,476,371 WARNING! (Details) 38,626,349 2 Slovakia 488,121 WARNING! (Details) 5,423,567 2 Slovenia 181,032 WARNING! (Details) 2,011,473 2 Switzerland 670,578 WARNING! (Details) 7,450,867 2 Presbyopia in Eastern Europe (Extrapolated Statistics) Belarus 927,946 WARNING! (Details) 10,310,520 2 Estonia 120,749 WARNING! (Details) 1,341,664 2 Latvia 207,567 WARNING! (Details) 2,306,306 2 Lithuania 324,710 WARNING! (Details) 3,607,899 2 Russia 12,957,665 WARNING! (Details) 143,974,059 2 Ukraine 4,295,887 WARNING! (Details) 47,732,079 2 Presbyopia in the Southwestern Europe (Extrapolated Statistics) Azerbaijan 708,154 WARNING! (Details) 7,868,385 2 Georgia 422,450 WARNING! (Details) 4,693,892 2 Portugal 947,173 WARNING! (Details) 10,524,145 2 Spain 3,625,270 WARNING! (Details) 40,280,780 2 Presbyopia in Southern Europe (Extrapolated Statistics) Greece 958,277 WARNING! (Details) 10,647,529 2 Italy 5,225,172 WARNING! (Details) 58,057,477 2 Presbyopia in the Southeastern Europe (Extrapolated Statistics) Albania 319,032 WARNING! (Details) 3,544,808 2 Bosnia and Herzegovina 36,684 WARNING! (Details) 407,608 2 Bulgaria 676,617 WARNING! (Details) 7,517,973 2 Croatia 404,718 WARNING! (Details) 4,496,869 2 Macedonia 183,607 WARNING! (Details) 2,040,085 2 Romania 2,011,999 WARNING! (Details) 22,355,551 2 Serbia and Montenegro 974,331 WARNING! (Details) 10,825,900 2 Presbyopia in Northern Asia (Extrapolated Statistics) Mongolia 247,618 WARNING! (Details) 2,751,314 2 Presbyopia in Central Asia (Extrapolated Statistics) Kazakhstan 1,362,933 WARNING! (Details) 15,143,704 2 Tajikistan 631,040 WARNING! (Details) 7,011,556 2 Uzbekistan 2,376,937 WARNING! (Details) 26,410,416 2 Presbyopia in Eastern Asia (Extrapolated Statistics) China 116,896,286 WARNING! (Details) 1,298,847,624 2 Hong Kong s.a.r. 616,961 WARNING! (Details) 6,855,125 2 Japan 11,459,970 WARNING! (Details) 127,333,002 2 Macau s.a.r. 40,075 WARNING! (Details) 445,286 2 North Korea 2,042,779 WARNING! (Details) 22,697,553 2 South Korea 4,341,038 WARNING! (Details) 48,233,760 2 Taiwan 2,047,485 WARNING! (Details) 22,749,838 2 Presbyopia in Southwestern Asia (Extrapolated Statistics) Turkey 6,200,452 WARNING! (Details) 68,893,918 2 Presbyopia in Southern Asia (Extrapolated Statistics) Afghanistan 2,566,230 WARNING! (Details) 28,513,677 2 Bangladesh 12,720,642 WARNING! (Details) 141,340,476 2 Bhutan 196,701 WARNING! (Details) 2,185,569 2 India 95,856,354 WARNING! (Details) 1,065,070,607 2 Pakistan 14,327,670 WARNING! (Details) 159,196,336 2 Sri Lanka 1,791,464 WARNING! (Details) 19,905,165 2 Presbyopia in Southeastern Asia (Extrapolated Statistics) East Timor 91,732 WARNING! (Details) 1,019,252 2 Indonesia 21,460,765 WARNING! (Details) 238,452,952 2 Laos 546,130 WARNING! (Details) 6,068,117 2 Malaysia 2,117,023 WARNING! (Details) 23,522,482 2 Philippines 7,761,752 WARNING! (Details) 86,241,697 2 Singapore 391,850 WARNING! (Details) 4,353,893 2 Thailand 5,837,897 WARNING! (Details) 64,865,523 2 Vietnam 7,439,652 WARNING! (Details) 82,662,800 2 Presbyopia in the Middle East (Extrapolated Statistics) Gaza strip 119,249 WARNING! (Details) 1,324,991 2 Iran 6,075,288 WARNING! (Details) 67,503,205 2 Iraq 2,283,722 WARNING! (Details) 25,374,691 2 Israel 557,910 WARNING! (Details) 6,199,008 2 Jordan 505,008 WARNING! (Details) 5,611,202 2 Kuwait 203,179 WARNING! (Details) 2,257,549 2 Lebanon 339,949 WARNING! (Details) 3,777,218 2 Saudi Arabia 2,321,634 WARNING! (Details) 25,795,938 2 Syria 1,621,518 WARNING! (Details) 18,016,874 2 United Arab Emirates 227,152 WARNING! (Details) 2,523,915 2 West Bank 208,008 WARNING! (Details) 2,311,204 2 Yemen 1,802,238 WARNING! (Details) 20,024,867 2 Presbyopia in Northern Africa (Extrapolated Statistics) Egypt 6,850,567 WARNING! (Details) 76,117,421 2 Libya 506,842 WARNING! (Details) 5,631,585 2 Sudan 3,523,334 WARNING! (Details) 39,148,162 2 Presbyopia in Western Africa (Extrapolated Statistics) Congo Brazzaville 269,823 WARNING! (Details) 2,998,040 2 Ghana 1,868,132 WARNING! (Details) 20,757,032 2 Liberia 305,157 WARNING! (Details) 3,390,635 2 Niger 1,022,448 WARNING! (Details) 11,360,538 2 Nigeria 1,597,532 WARNING! (Details) 12,5750,356 2 Senegal 976,693 WARNING! (Details) 10,852,147 2 Sierra leone 529,550 WARNING! (Details) 5,883,889 2 Presbyopia in Central Africa (Extrapolated Statistics) Central African Republic 336,823 WARNING! (Details) 3,742,482 2 Chad 858,468 WARNING! (Details) 9,538,544 2 Congo kinshasa 5,248,532 WARNING! (Details) 58,317,030 2 Rwanda 741,480 WARNING! (Details) 8,238,673 2 Presbyopia in Eastern Africa (Extrapolated Statistics) Ethiopia 6,420,291 WARNING! (Details) 71,336,571 2 Kenya 2,968,389 WARNING! (Details) 32,982,109 2 Somalia 747,414 WARNING! (Details) 8,304,601 2 Tanzania 3,246,371 WARNING! (Details) 36,070,799 2 Uganda 2,375,123 WARNING! (Details) 26,390,258 2 Presbyopia in Southern Africa (Extrapolated Statistics) Angola 988,069 WARNING! (Details) 10,978,552 2 Botswana 147,530 WARNING! (Details) 1,639,231 2 South Africa 4,000,362 WARNING! (Details) 44,448,470 2 Swaziland 105,231 WARNING! (Details) 1,169,241 2 Zambia 992,312 WARNING! (Details) 11,025,690 2 Zimbabwe 330,467 WARNING! (Details) 1,2671,860 2 Presbyopia in Oceania (Extrapolated Statistics) Australia 1,792,182 WARNING! (Details) 19,913,144 2 New Zealand 359,443 WARNING! (Details) 3,993,817 2 Papua New Guinea 487,825 WARNING! (Details) 5,420,280 2North AmericaCanadaWARNING! (Details) MexicoWARNING! (Details)BelizeWARNING! (Details)GuatemalaWARNING! (Details)NicaraguaWARNING! (Details)Puerto RicoWARNING! (Details)South AmericaBrazilWARNING! (Details)ChileWARNING! (Details)ColombiaWARNING! (Details)Paraguay WARNING! (Details)PeruWARNING! (Details)VenezuelaWARNING! (Details)DenmarkWARNING! (Details)FinlandWARNING! (Details)IcelandWARNING! (Details)SwedenWARNING! (Details)United KingdomWARNING! (Details)BelgiumWARNING! (Details)FranceWARNING! (Details)IrelandWARNING! (Details)LuxembourgWARNING! (Details)MonacoWARNING! (Details)NetherlandsHolland WARNING! (Details)United KingdomWARNING! (Details)WalesWARNING! (Details)AustriaWARNING! (Details)Czech RepublicWARNING! (Details)GermanyWARNING! (Details)HungaryWARNING! (Details) LiechtensteinWARNING! (Details)PolandWARNING! (Details)SlovakiaWARNING! (Details)SloveniaWARNING! (Details) SwitzerlandWARNING! (Details)BelarusWARNING! (Details)EstoniaWARNING! (Details)LatviaWARNING! (Details)LithuaniaWARNING! (Details)RussiaWARNING! (Details)UkraineWARNING! (Details)AzerbaijanWARNING! (Details)GeorgiaWARNING! (Details)Portugal WARNING! (Details)SpainWARNING! (Details)GreeceWARNING! (Details)ItalyWARNING! (Details)AlbaniaWARNING! (Details)WARNING! (Details)BulgariaWARNING! (Details)CroatiaWARNING! (Details)MacedoniaWARNING! (Details)RomaniaWARNING! (Details)WARNING! (Details)MongoliaWARNING! (Details)KazakhstanWARNING! (Details)TajikistanWARNING! (Details)UzbekistanWARNING! (Details)ChinaWARNING! (Details) JapanWARNING! (Details) North KoreaWARNING! (Details)South KoreaWARNING! (Details)Taiwan WARNING! (Details)TurkeyWARNING! (Details) AfghanistanWARNING! (Details)BangladeshWARNING! (Details)BhutanWARNING! (Details)IndiaWARNING! (Details)PakistanWARNING! (Details)Sri LankaWARNING! (Details)East Timor WARNING! (Details)IndonesiaWARNING! (Details)LaosWARNING! (Details)MalaysiaWARNING! (Details)PhilippinesWARNING! (Details)SingaporeWARNING! (Details)ThailandWARNING! (Details)VietnamWARNING! (Details) IranWARNING! (Details)IraqWARNING! (Details) IsraelWARNING! (Details)JordanWARNING! (Details)KuwaitWARNING! (Details)LebanonWARNING! (Details)Saudi ArabiaWARNING! (Details)SyriaWARNING! (Details)United Arab EmiratesWARNING! (Details) YemenWARNING! (Details)EgyptWARNING! (Details)LibyaWARNING! (Details)SudanWARNING! (Details)Western AfricaWARNING! (Details)Ghana WARNING! (Details)LiberiaWARNING! (Details)NigerWARNING! (Details)NigeriaWARNING! (Details)Senegal WARNING! (Details)Sierra leoneWARNING! (Details)Central AfricaCentral African RepublicWARNING! (Details)ChadWARNING! (Details) RwandaWARNING! (Details)Eastern AfricaEthiopiaWARNING! (Details)KenyaWARNING! (Details)SomaliaWARNING! (Details)Tanzania WARNING! (Details)UgandaWARNING! (Details)AngolaWARNING! (Details)BotswanaWARNING! (Details)South AfricaWARNING! (Details)SwazilandWARNING! (Details)ZambiaWARNING! (Details) ZimbabweWARNING! (Details)OceaniaAustraliaWARNING! (Details)New ZealandWARNING! (Details)Papua New GuineaWARNING! (Details)  About extrapolations of prevalence and incidence statistics  Read more at IMPORTANCE !!!! Prevalance Rate for Presby opia : Approx 1 in 11 = 9.00% or 24.5 M. people in USA Read more at ESCRS 2011

9 CONCEPTS OF RESTORING ACCOMODATION  MONOVISON:not physiological  LASER TREATMENT OF THE CORNEA?monovion multifocality -the problem is not there  SCERAL EXPANSION PROCEDURES :doubtful results  ACCOMODATIVE LENSES -DEFORMABLE ACCOMODATING IOLS Mechanical concepts based on axial shift principle have very limited accomodative effect  REFILLING THE EMPTY LENS CAPSULE:WITH SOFTER MATERIAL experimantal stage !!!! See later ESCRS 2011

10 HOW TO MAKE A BETTER LENS ?  A more basic treatment should be derived from treating the root cause of presbyopia: to make the lens substance softer  A newer technique - currently proposed - consists of mechanically softening the lens substance using femto-second laser pulses  Or one can insert an ersatz lens available now ESCRS 2011

11 FUTURE EUROTIMES DOUGH KOCH  IN REFRACTIVE AND CATARACT SURGERY PRESBYOPIA CORRECTION WILL BECOME THE NORM  THE HOLY GRAIL OF ACCOMODATIVE LENSES IS BECOMING CLOSER BUT HOW CLOSE? ESCRS 2011

12 LET US CONCENTRATE ON THE PHACO ERSATZ HOW TO BRING A NEW ARTIFICAL BETTER FUNCTIONING LENS IN AN OLDER EYE ESCRS 2011

13 THE EYE IN HISTORY IMPORTANT DISCOVERIES HOW FAR ARE WE NOW? HOW SLOW DID IT GO UNTILL NOW ! WHAT WILL THE FUTURE BRING? ESCRS 2011

14 MAJOR STEPS IN EYE SURGERY  Jacques Daviel 1735 first real cataract surgery  Harold Ridley 1955 first iol  Kelman phaco first phaco ESCRS 2011

15 DISCOVERY OF LIGHT At that time the popular belief was the emanation hypothesis of vision,advanced by Pythagoras (c. 600 B.C.) and accepted by such classical writers as Euclid, Hipparchos and Ptolemy and after them by Galen. In this hypothesis the visual spirit originating in the brain emanated from the lens (the essential organ of vision) forming a cone of linear At C wave–particle duality, described by Albert Einstein in the early 1900s,wave–particle dualityAlbert Einstein IBN al-Haitham ( ESCRS 2011

16 DISCOVERY OF SPECTACLES Venice Murano 1270 and Gutenberg’s invention of the printing press 1450 ESCRS 2011

17 DISCOVERY OF ANATOMY AND FUNCTION OF THE EYE Georg Bartisch( ) surgeon and oculist of Dresden published the first systematic work on ocular disease ESCRS 2011

18 JACQUES DAVIEL FRANCE 1745 FIRST REAL CATARACT SURGERY ECCE ESCRS 2011

19 HAROLD RIDLEY THE FIRST IOL 1949 Sir Harold Ridley and his wife- medal received at the knighthood ceremony ESCRS 2011

20 CHARLIE KELMAN receiving presedential award from G.Bush Sr. Modern Era of cataract surgery 1967 ESCRS 2011

21  1987 JEAN MARIE PAREL PHACO ERSATZ  The Ophthalmic Biophysics Center created in Bascom Palmer- director Dr. Edward Norton and Dr. Parel  WHAT HAPPENED SINCE THEN ????  PERSONAL EXPERIENCE  TRUE VISTA STORZ 3 ZONE DESIGN 1992  3M APODIZED PRINCIPLE 1992 ESCRS 2011

22  FDA PANEL RECOMMENDS APPROVAL OF 3M MULTIFOCAL INTRAOCULAR LENS ST. PAUL, Minn., Jan. 23 /PRNewswire/ -- The Food and Drug Administration's Ophthalmic Advisory Panel today recommended approval with conditions, of the 3M (NYSE: MMM) brand Multifocal intraocular lens (IOL) for sale in the United States. The conditions are related mainly to labeling. The FDA relies on the clinical expertise of the advisory panels to guide its decisions. Generally, approval to market follows advisory panel recommendation. "The advisory panel's recommendation represents an important step forward in making this advanced lens available to ophthalmologists for treatment of cataract patients in the United States," said Robert B. Bomar, manager, 3M Vision Care. "The lens will be commercially available only after final approval by the FDA," Bomar added. Since 1987, the lens has been implanted in approximately 30,000 cataract patients worldwide. Of those, over 700 were involved in the U.S. study, which is currently under review by the FDA. An individual who undergoes cataract surgery and receives a conventional monofocal lens implant typically needs to wear eyeglasses, usually bifocals, following surgery to achieve acceptable near and far vision. The majority of patients implanted with bilateral 3M Multifocal IOLs, however, do not need to wear bifocals; and about half of these patients function entirely without the aid of eyeglasses. The lens has been available for sale to ophthalmologists in most countries for over two years. In March 1991, the 3M Multifocal intraocular lens was the first multifocal lens to receive commercial marketing approval from Japan's Ministry of Health and Welfare /23/92 ESCRS 2011

23 DID IT WORK ?DID IT LAST?  YES IT WORKED !!  BUT NO SMALL INCISION POSSIBLE SINCE NO Foldable IOL  mm. PMMA MATERIAL  NEEDED SUTURING  CREATED ASTIGMATISM  SO IT WAS NOT THE FINAL SOLUTION ESCRS 2011

24 WHERE DO WE GO? PREDICTION IS VERY DIFFICULT SPECIFICALLY ABOUT THE FUTURE ESCRS 2011

25 Newer succesfull models  ALCON RESTOR/old 3M apodized principle 2001  ABBOTT AMO TECNIS:Ring principle 2003  Later on adapations; add on near zone material changes etc.etc.etc.etc. ESCRS 2011

26 Tecnis  One Piece ZMBOO Full diffractive posterior surface Wavefront-designed aspheric anterior surface Newest generation Acrylic material Near addition +4D=3.1 pupil plane One piece iol : One piece iol :+5.0 D to D in 0.5 D increments Ease of insertion Performance is Pupil Independent ESCRS 2011

27 New trends EUROTIMES MAY 2011 TOO MANY TO BE GOOD  Dual optic Synchrony -iol more effect for less movement-2.5 D pro 1 mm.  Opti-K new form of laser thermal keratoplasty LTK.Adv.it can be repeated why?because regression  Palliklaris group:WIOL-CF accomodative iol2D of pseudo-accomodation. ?? ESCRS 2011

28 ACCOMODATION FACTS  The ciliary muscle remains active even at older age;the problem does not ly there.  Mechanical concepts based on axial shift principle have very limited accomodative efefct  Phamacolgical stimulation of the ciliary muscle (Guthoff)it moves in the direction of the lens-0.04 to 0.26 mm.depending on age and subject.  New artificial materials for lens refilling are promising but are still at an experimental stage ESCRS 2011

29 INJECTABLE ACCOMODATIVE LENSES-AN INJECTED GEL LENS  IS NOT A NEW CONCEPT !!!!  MATERIAL USED_ SILICONE -polyethelene- poloxamer-monomer mixture-silicone polymer gel   First publ:1964 Kessler J.Arch.ophtahl. 71, Experiments in refilling the lens. ESCRS 2011

30 SOME MAJOR PROBLEMS REMAIN  CREATING A MINICAPSULORHEXIS<2MM : we need innovative instruments and extensive surgical training  PHACO THROUGH A 1 MM HOLE :innovative approach  SEALING THE MICROCAPSULORHEXIS : to prevent leakage ESCRS 2011

31 SOME MAJOR PROBLEMS REMAIN  POLYMER BIOCOMPATIBILITY: many materials used for iols have passed years of biocompatibility testing.  LENS CAPSULAR VOLUME VARIABILITY:varies among patients-the optimum volume should be controlled for each different eye.  POLYMER REFRACTION:desired refraction will be different for each patient-controlling the amount of gel is a challenge.  PREVENTING PCO: challenge yag has to be avoided because will create leakage of the injected gel ESCRS 2011

32 FACTS  PCO PREVENTION WILL REMAIN THE PROBLEM NR 1  New materials Guthoff Rostock:pure water-methotrexate mtx antimetabolite-Actinomycin AM = antibioticun-Daunomycin- Disulfiram.  Untill now tested: -Cytostatic drugs:5Fluouracil-Colchicine-Doxoribin- Mitomycin C-Methotrexate-Doxorubicin Anti-inflammatory: Diclofenac-dexamethasone Immunological agents:cyclopsorine A Further Investigations involving non-primates are needed Cave:Endothelial cells ESCRS 2011

33 A PARADIGM SHIFT NEEDED? INVENTION OF Train 1803 Bicycle 1839 !!! ESCRS 2011

34 MULTIFOCAL IOLS WILL BE HERE FOR ANOTHER YEARS BUT THEY WILL IMPROVE ! ESCRS 2011

35 WILL EVENTUALLY THE DREAM OF PHACO ERSATZ COME REALITY ?  PROBABLY YES  BUT WE NEED  MORE TIME ESCRS 2011

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