August 28, 2012 Annual Meeting Highlights
Tuesday
On Tuesday, the 30th ASRS Annual Meeting featured the:
- Trauma/Pharmacology Symposium
- Inflammation Symposium
- Infections Symposium
- AMD III Symposium
- Retinal Surgery II Symposium
Retina Image Bank: Image of the Day
Sickle Cell Retinopathy with Sea Fans
Geoffrey G. Emerson, MD, PhD
Fundus camera
Fluorescein angiography (early/mid phase) of a 40-year-old man with African heritage and sickle SC disease. Sea fans are present temporal to the macula (leaking fluorescein)
Trauma/Pharmacology Symposium
Tuesday, August 27, 7:30-7:48 AM
Moderators: Dante Pieramici, MD, Phil Ferrone, MD
Reported by Mina Chung, MD
Rochester, New York
Airsoft BBs: The Blinding Truth
Presenter: Timothy Saunders, MD
Timothy Saunders et al reported a case of Airsoft, a recreational hard plastic BB, causing severe eye injury including ruptured globe and intraocular foreign body fragments, best visualized by B-scan. An experimental model using the Airsoft on autopsy eyes demonstrated that Airsoft BBs can shatter into multiple fragments and can penetrate the posterior segment.
Autofluorescence, OCT, EDI-OCT, and Management of Acute Subfoveal Hemorrhage Secondary to Blunt Trauma +/-Parafoveal Choroidal Rupture
Presenter: Pradeepa Yoganathan, MD
Pradeepa Yoganathan reviewed 6 cases of subfoveal hemorrhage after blunt trauma. Enhanced depth imaging (EDI-OCT) showed choroidal thinning in all cases when compared to the fellow eye (mean decrease 35 microns). Fundus autofluorescence delineated RPE disturbance in areas of resolved hemorrhage, but these changes did not correlate with visual acuity.
Bacterial Susceptibility Profiles in Trauma-Associated Endophthalmitis
Presenter: Duncan Friedman, MD, MPH
Duncan Friedman et al reported a retrospective review of 33 cases of trauma-associated endophthalmitis in Birmingham, Alabama over 4 years. Fifty-six percent of cases were culture-positive, and of these, 93% showed gram-positive organisms and 39% showed multiple organisms.
All gram-positive organisms were susceptible to vancomycin, and all gram-negative organisms were susceptible to third-generation cephalosporins. Clinicians should ensure that testing laboratories include organisms and sensitivities relevant to eye infections in their panels.
Inflammation Symposium
Tuesday, August 27, 7:48-8:38 AM
Moderators: Dante Pieramici, MD, Phil Ferrone, MD
Reported by Mina Chung, MD
Rochester, New York
Characteristics, Complications, and Surgical Outcomes of Panuveitis Over 25 Years: The KKESH Uveitis Survey Study Group
Presenter: J. Fernando Arevalo, MD, FACS
Fernando Arevalo et al reviewed 727 eyes of 400 patients with panuveitis treated at King Khaled Eye Specialist Hospital in Riyadh, Saudi Arabia, over a 25-year period. Seventy-three percent of cases were bilateral, 60% recurrent, and 38% had visual acuity worse than 20/200.
Predominant diagnoses were Vogt Koyanagi Harada (38%) and Behcet disease (26%). Forty-five percent of cases required surgery, most frequently cataract surgery (75%) and pars plana vitrectomy (12%).
Voclosporin: Efficacy and Safety in Noninfectious Uveitis Involving the Posterior Segment
Presenter: Shree Kurup, MD
Shree Kurup et al presented results from the LUMINATE Phase 2/3 trials of oral voclosporin, a calcineurin phosphatase inhibitor, for posterior noninfectious uveitis. The LX211-01 trial showed decreased vitreous cell at 16 weeks in eyes with active uveitis treated with voclosporin compared to placebo. The LX211-02 trial did not meet its primary endpoint, but suggested a reduced recurrence rate at 6 months.
Clinical Utility of Serologic and Radiologic Testing in the Evaluation of the White-Dot Syndromes
Presenter: Steven Yeh, MD
Steven Yeh et al reviewed 47 patients with white-dot syndromes presenting to Emory Eye Center over a 4-year period, and assessed the yield of serologic and radiographic testing. Fifty-three percent of cases had birdshot chorioretinopathy. A total of 220 tests were performed, of which 29 tests were positive. HLA-A29 was positive 17/18 times and TB testing was positive 4/12 times, prompting isoniazid therapy. Workup should be focused to tests that would influence management.
Fluocinolone Acetonide Implant versus Systemic Therapy For Noninfectious Uveitis: Combined Results Of Three Clinical Trials
Presenter: Sunil Srivastava, MD
Sunil Srivastava et al reported on a pooled dataset from 3 clinical trials of the fluocinolone acetonide implant (total 1170 eyes). Implanted eyes had worse visual acuity at baseline, were more likely to have 2 lines of visual acuity improvement, and had fewer recurrences after 2 years. Implanted eyes also had a high rate of cataract and glaucoma surgery.
Visual Outcomes in Uveitis with Angiographic Macular Leakage Treated With the Fluocinolone Acetonide Implant or Standard Treatment
Presenter: Thomas Albini, MD
Thomas Albini et al reported on patients with angiographic macular leakage from the same dataset. The implanted group (250 eyes) had more macular leakage at baseline and had significantly greater improvement in visual acuity after 2 years, compared to standard of care (163 eyes) and fellow eye (59 eyes) groups.
Infections Symposium
Tuesday, August 28, 8:38-9:30 AM
Moderators: John Prenner, MD, Harry Flynn, MD
Reported by Jeremiah Brown, MD, MS
Schertz, Texas
Antibacterial Properties of 2 Percent Lidocaine on Staphylococcus and Streptococcus Species and Reduced Rate of Post-injection Endophthalmitis
Presenter: Stephen Kim, MD
In a study of over 13,000 intravitreal injections comparing subconjunctival lidocaine and other methods of anesthesia, a higher rate of endophthalmitis was found in the other methods group (N = 7961). No cases of endophthalmitis were found in the subconjunctival lidocaine 2% anesthesia group (N = 6685). Furthermore, 2% lidocaine with 0.1% methylparaben demonstrated rapid bactericidal effect in vitro.
Laboratory Investigation of an Endophthalmitis Outbreak Caused by Streptococcus Mitis/Oralis Group After Intravitreal Injection of Bevacizumab
Presenter: Harry Flynn, MD
After studying the recent endophthalmitis outbreak following intravitreal injection in South Florida, CDC and the Florida Health Department studies confirmed Strep mitis/oralis contamination of the prepackaged bevacizumab syringes as the most likely source of the outbreak.
Outbreak of Fusarium Endophthalmitis Following Brilliant Blue G (BBG) Dye-Assisted Vitrectomy Procedures
Presenter: Michael Davis, MD
This study reported the clinical findings and treatment course following endophthalmitis due to Brilliant Blue dye contamination by Fusarium species, from one compounding pharmacy in Florida.
Take-home points:
- Maintain a high degree of suspicion.
- Treat early and aggressively.
- Remove IOL and bag early.
- Be hypervigilant, record lot numbers, know your pharmacy.
- Report adverse events.
Endophthalmitis Following Vitrectomy: A Prospective and Nationwide UK Study
Presenter: Somdutt Prasad, MD, FRCSEd, FRCOphth, FACS
A prospective nationwide case-control study of endophthalmitis cases in the UK was reported. An approximate incidence 1: 1.760 was found. PPV for diabetic vitreous hemorrhage was the major risk factor.
Pars Plana Vitrectomy in the Management of Patients Diagnosed With Endophthalmitis Following Intravitreal Anti-VEGF Injection
Presenter: Juan Romero, MD
The report described the findings in a group of patients experiencing endophthalmitis after intravitreal anti-VEGF injection. Patients who required vitrectomy had a poorer visual outcome. Dr. Flynn commented that the virulence of the organism is the major predictor of outcome, regardless of the treatment strategy employed.
AMD III Symposium
Tuesday, August 28, 9:30-10:56 AM
Moderators: Susan Bressler, MD, Lawrence Singerman, MD
Reported by Jeremiah Brown, MD, MS
Schertz, Texas
Response to Treat-and-Extend Therapy in Wet-AMD Patients Shows Differentially Expressed Proteins Specific to CNV Signaling Pathways Shed Into the Vitreous
Presenter: Bert Glaser, MD
In-office vitreous aspirates were performed on patients at the time of their intravitreal injection. Proteomic studies were performed. VEGF A, eNOS, AKT, were found to be elevated in patients with stable vision and edema. This pathway affects vascular permeability/relaxation and may be important in patients with leakage and no loss of vision.
In unstable patients with loss of vision and increased edema, the MAPK pathway was found to be more active. Recent studies showed that MAPK activation may increase the resistance to inhibitors of the VEGF receptor.
Visual Acuity Response as a Function of the Affinity and Vitreous Half-Life of Intravitreally Administered Anti-VEGF Agents
Presenter: Robert Avery, MD
- There appears to be a high affinity threshold, beyond which further affinity improvement does not translate to increased efficacy.
- Aflibercept and ranibizumab demonstrate similar potency in BREC (an endothelial proliferation assay).
- Following intravitreal injection, serum concentrations of aflibercept and bevacizumab were higher for longer compared to ranibizumab in a primate study.
- Fellow eye effect: slower rate of fellow eye CNV was found in patients receiving bevacizumab in the CATT study.
- In Year 2 of the View-1 and View-2 studies, 4.7 ranibizumab injections were given and 4.2 injections aflibercept were given.
- Affinity assays are less predictive of clinical efficacy than 1) potency and 2) the results of clinical trials.
Intraocular Pressure in Patients with Neovascular AMD Receiving Intravitreal Aflibercept Injection or Ranibizumab
Presenter: K. Bailey Freund, MD
Prevalence of IOP elevation was highest in the ranibizumab eyes compared to aflibercept. Interestingly, the same pattern was found in the fellow eyes. Incidence of IOP increases were low and similar among intravitreal aflibercept groups. Compared to ranibizumab groups, aflibercept had significantly lower incidence of IOP ≥ 25.
Autologous Transplantation of RPE and Choroid for the Treatment of Wet AMD: Functional Results and Prognostic Factors after a Long-Term Follow Up
Presenter: Barbara Parolini, MD
The results of 84 patients were discussed. A free graft of retina and choroid is the only way to maintain the correct orientation of the RPE cells. The best results were obtained in patients with the best preoperative vision. Eyes with preoperative RPE tears have a poorer prognosis.
The improvement in vision is a slow and progressive process over months.
Retinal detachment and PVR occurred in 14% of patients. Twenty-three percent of eyes lost vision due to complications. There was a 6% rate of CNV relapse.
Patient Perceptions of the Treatment Regimen and Expected Outcomes of Intravitreal Anti-VEGF Injections for Wet Age-Related Macular Degeneration
Presenter: Tarek Hassan, MD
The results of a patient questionnaire were discussed.
- Retina surgeons and industry representatives underestimate patients' willingness to continue intravitreal injections indefinitely to maintain their vision.
- Patients prefer PRN injections over planned monthly injections.
- Patients think more about FDA approval status in choosing a drug than retina surgeons do.
- Early in the treatment regimen, patients have a higher expectation of a cure than those who have had more than 10 injections.
- Twenty-five percent of patients would never consider surgery for treatment of their neovascular AMD.
High-Dose 2 mg Ranibizumab, Continuous Monthly Treatment, for Polypoidal Choroidal Vasculopathy (PCV) - 6-Month Results
Presenter: Gregg Kokame, MD, MMM
This study compared the use of monthly 2.0 mg ranibizumab with the results of a previous study using monthly 0.5 mg ranibizumab for the treatment of polypoidal choroidal vasculopathy (PCV).
Higher polyp regression/closure rate was found in the 2.0 mg ranibizumab study compared with the 0.5 mg ranibizumab study: 63% vs 33%. Visual acuity results were similar in both studies.
Retinal Surgery II Symposium
Tuesday, August 28, 10;56 AM-12:22 PM
Moderators: Mark Humayun, MD, PhD, Lawrence Halperin, MD
Reported by Tamer Mahmoud, MD, PhD
Durham, North Carolina
MIVS 23-Gauge Pars Plana Vitrectomy Management of Complex Retinal Detachment in Eyes with Brachytherapy-Treated Posterior Uveal Melanoma
Presenter: Timothy Murray, MD, MBA
- 23-gauge pars plana vitrectomy (MIVS) can effectively manage complex retinal detachments in eyes having undergone definitive 125-iodine brachytherapy for uveal melanoma.
- Complex detachments included exudative, tractional, and less rhegmatogenous.
Many achieved good visual outcome, 20/40 or better in 48%. - 100% survival.
Pars Plana Vitrectomy with Medium-Term Perfluoro-n-octane for Recurrent Inferior Retinal Detachment Complicated by Proliferative Vitreoretinopathy
Presenter: Steve Charles, MD
- Medium-term PFO was found to be an efficacious technique for operative management of recurrent inferior retinal detachments complicated by grade C PVR, with successful reattachment in 86% of eyes (38/44).
- All 44 eyes of 44 patients were attached initially under air and PFO was injected at the conclusion of the procedure.
- This required a second procedure to remove PFO.
23-Gauge Endoscopic Vitrectomy for Complicated Retinal Diseases
Presenter: Jeffrey Heier, MD
23-gauge endoscopic vitrectomy can be an important addition to the retina surgeon's surgical armamentarium in the management of complicated retinal diseases with difficult visualization to the posterior segment.
Oral Fluoroquinolones and the Risk of Retinal Detachment
Presenter: David Maberley, MD, FRCS(C)
- In this nested case-control study, there is evidence to suggest that oral fluoroquinolones increase the risk of rhegmatogenous retinal detachment.
- The absolute increased risk of RD in current users was 4 per 10,000 person-years.
- The population attributable risk is about 4% and would account for approximately 1440 cases of detachment annually in the US.
- The average time between prescription and RD was 4.8 days.
Pneumatic Retinopexy in 1000 Eyes With Rhegmatogenous Retinal Detachment: What Have We Learned?
Presenter: Thierry Verstraeten, MD
Successful repair of primary retinal detachment with pneumatic retinopexy was greater than 70% in this series of 1000 cases. Appropriate case selection can achieve higher success rates.
Optic Neuropathy Following Vitrectomy for Retinal Detachment: Clinical Features and Analysis of Risk Factors
Presenter: Alok Bansal, MD
Retrospective case-control study where 8 eyes developed optic neuropathy following PPV for macula-sparing primary RRD.
This rare but devastating complication is of unclear etiology. Intraoperative systemic hypotension may lead to reduced ocular perfusion pressure and may be a contributing risk factor.
The Minimally Invasive 25-Gauge Vitreoretinal Surgery with Perfluoropropane or Air Tamponade in the Treatment of Rhegmatogenous Retinal Detachments
Presenter: Cesare Mariotti, MD
This retrospective study included 85 eyes of 85 patients with rhegmatogenous retinal detachment with 65% macula-off. Breaks distribution included 80% superior breaks and 20% inferior breaks. All underwent primary 25-gauge pars plana vitrectomy.
Primary reattachment rate was 86% with C3F8 and 94% with just air tamponade.
Epiretinal Membrane Formation and Cystoid Macular Edema Following Uncomplicated Primary Retinal Detachment Repair With Small-Gauge Pars Plana Vitrectomy
Presenter: Gayatri Reilly, MD
In this retrospective study of uncomplicated small gauge vitrectomy for primary RRD, incidence of ERM was 30.3% and CME 14.75% following repair.
A significantly higher incidence of ERM, but not CME was observed with SB/PPV compared with PPV alone.
Retained Subretinal Perfluorocarbon Liquid in Sutureless 23-Gauge versus Sutured 20-Gauge Vitrectomy for Retinal Detachment Repair
Presenter: Sunir Garg, MD
In this retrospective study, there was a significant 4.5-fold higher incidence of retained PFCL in eyes undergoing RRD repair with sutureless 23-gauge vs 20-gauge PPV.
Higher fluid flow through open 23-gauge cannulas may be implicated.
Comparative Study of Vitrectomy With and Without Internal Limiting Membrane Peeling for Rhegmatogenous Retinal Detachment
Presenter: Cyrus Shroff, MD
This small retrospective study showed less macular pucker developing in eyes with Brilliant Blue-assisted ILM peeling as part of their primary repair of not recent RRD compared with a group with no ILM peel.
Infero-Temporal Dialysis: A Genetic RRD in the Andes?
Presenter: Armando Sandoval, MD
This retrospective study showed that inferotemporal dialysis (ITD) is a common cause of spontaneous RRD in the Ecuadorian Andes (34%). It can be bilateral in up to 59% and is more common in young males between 15 and 35 years of age. Most can be successfully repaired with a scleral buckle. Genetic or environmental factors are a suggested etiology.
Posters
Reported by Pouya N. Dayani, MD
Los Angeles, California
AMD: Neovascular
104: In patients with neovascular AMD, foveal photoreceptor integrity is closely associated with final VA following treatment. Initial VA, IS/OS and ELM integrity, CMT, and CNV height are correlated with final photoreceptor integrity.
106: Eyes with submacular hemorrhage secondary to neovascular AMD may experience significant visual and anatomic improvements when managed with anti-VEGF monotherapy, with a mean gain of 23 letters at 6 months.
109: Intravitreal gas injection followed by prone positioning may be effective in displacing SRH from the macula in most patients with submacular hemorrhage. This procedure, however, is often complicated by breakthrough vitreous hemorrhage or recurrent SRH, requiring additional surgical intervention.
113: PDT can be effective in the management of neovascular AMD when the lesion becomes refractory to anti-VEGF monotherapy. The response to subsequent PDT, however, is not as good as that of the first treatment.
114: Endophthalmitis following intravitreal anti-VEGF therapy presents with features distinctly different from those following cataract surgery, including painless vision loss and significant vitreous exudates. Pars plana vitrectomy is often necessary for management.
116: The majority of submacular hemorrhages occur beyond 6 weeks after a prior anti-VEGF treatment (mean and median interval of 16 and 7 weeks, respectively). These findings have implications in discussing compliance with patients and regarding extended or PRN dosing.
120: Intravitreal aflibercept (2.0 mg) provides significant anatomical improvement, with a trend toward visual improvement, in patients with neovascular age AMD who have persistent foveal fluid despite previous treatments with other VEGF antagonists.
AMD: Non-neovascular
122: Acquired vitelliform lesions may be associated with large drusen in patients with non-neovascular age-related macular degeneration.
123: Aging of human Bruch's membrane causes multiple deleterious effects on the behavior of the overlying RPE, which impairs cellular homeostasis.
Diabetic retinopathy
203: Treatment of POAG with ocular hypotensive lipids seems not to affect the incidence, progression, or response to treatment of macular edema among diabetics.
208: Focal laser treatment using the NAVILAS system, as monotherapy or in combination with bevacizumab, appears to be safe and well-tolerated at 1 year in patients with DME.
211: Treatment with intravitreal or sub-Tenon steroid can be effective in the management of patients with diabetic macular edema who have failed anti-VEGF therapy.
212: Treatment with intravitreal anti-VEGF therapy may provide better visual outcome compared to focal/grid laser photocoagulation in the management of DME.
214: Population-based diabetic eye care in developing economies is challenged by unmet needs not adequately addressed by current conceptual frameworks and interventional strategies.
Hereditary retinal disease and genetics
217: Progressive constriction of the hyperautofluorescent ring and a concordant decrease in IS/OS junction length can be observed over time in patients with retinitis pigmentosa.
Inflammatory and infectious diseases
220: Primary vitrectomy, regardless of presenting visual acuity, may be a safe and effective method in the management of post-cataract surgery endophthalmitis.
221: Biome representational in silico karyotyping (BRISK) represents a novel method of identifying bacterial and viral species from aqueous and vitreous specimens in eyes with infectious endophthalmitis.
224: The Ozurdex implant is an effective treatment option for patients with noninfectious intermediate uveitis, providing an improvement in ocular inflammation and macular edema.
225: Intravitreal injections may be administered safely and with a very low risk of endophthalmitis when povidone-iodine is used for ocular surface preparation. Use of topical prophylactic antibiotics appears unnecessary for endophthalmitis risk reduction.
230: Frosted branch retinal angiitis can be an atypical manifestation of SLE. Despite a dramatic presentation and severe vision loss, resolution of retinal lesions and visual recovery can be seen.
231: Absence of the posterior lens capsule is the main risk factor for anterior migration of an Ozurdex implant. The implant may be removed in its entirety with forceps or with the assistance of automated aspiration to reduce the risk of corneal decompensation.