August 29, 2012 Annual Meeting Highlights
Wednesday
On Wednesday, the 30th ASRS Annual Meeting concluded with the:
- Macular Surgery II/Anterior-Segment Surgery Symposium
- AMD IV Symposium
- Pediatric Retina Symposium
- Diabetic Retinopathy II Symposium
- Instrumentation/Pharmacology Symposium
Retina Image Bank: Image of the Day
Proliferative Diabetic Retinopathy
John S. Pollack, MD
Fundus camera
Macular Surgery II/Anterior-Segment Surgery Symposium
Wednesday, August 29, 8:30-9:30 AM
Moderators: Kourous Rezaei, MD, Tarek Hassan, MD
Reported by Mitchell J. Goff, MD
Salt Lake City, Utah
Postoperative Posterior-Segment Complications in Eyes Treated With the Boston Type I Keratoprosthesis
Presenter: Darin Goldman, MD
A retrospective chart review of 93 keratoprosthesis procedures with a mean follow-up of 28.2 months revealed a 40% risk of posterior segment complications including retinal detachment (16.9%), choroidal detachment (16.9%) and sterile vitritis (14.5%).
Eyes with keratoprosthesis and posterior segment complications had overall worse vision (39% better than 20/200) than eyes with keratoprosthesis and no posterior segment complications (76% better than 20/200).
Visual and Surgical Outcome of Surgery (Retrieval, Suturing or Secondary Implant) for Posteriorly Dislocated IOLs in a Single Retina Procedure
Presenter: Rajiv Anand, MD
A series of 40 eyes with dislocated PCIOL demonstrated improvement in vision at 3-60 months (mean of 17 months) in all eyes after a single surgery pars plana vitrectromy and repositioning or replacement of the intraocular lens.
In 18 eyes, the undamaged lens was placed in the ciliary sulcus with sutures. In 10 eyes, the lens was damaged and was replaced with a new lens through a limbal incision and sutured in the ciliary sulcus. In 2 eyes, an ACIOL was placed.
Prospective Retinal and Optic Nerve Vitrectomy Evaluation (PROVE) Study: Baseline Findings
Presenter: Maziar Lalezary, MD
The PROVE study is a 5-year longitudinal analysis of eyes undergoing unilateral pars plana vitrectomy to evaluate long-term outcomes compared to the non-vitrectomized fellow eye.
Patients undergoing routine pars plana vitrectromy surgery for epiretinal membrane, macular hole, or vitreous opacity may have unidentified risks for glaucoma at baseline, specifically narrow angles (found in 13%) and abnormal visual field tests (found in 18%).
The authors propose that vitreopapillary traction may contribute to vision loss in ERM, as the mean temporal RNFL thickness was greater at baseline in patients with ERM.
Correlation Between the Unaided Observation of the ILM and Brilliant Blue-Stained ILM Following ERM Peeling: Results of the PACORES Group
Presenter: Lihteh Wu, MD
In this prospective multicenter observational case series, even experienced surgeons were unable to accurately evaluate the integrity of the unstained ILM when compared to stained (Brilliant Blue G) ILM, suggesting that staining of the ILM does provide meaningful improvement in visualization.
Intraoperative Optical Coherence Tomography Use During Epimacular Membrane Removal With Internal Limiting Membrane Peeling
Presenter: Ching Chen, MD
In this series of 30 patients, comparison of intraoperative SD-OCT images including pre-epimacular membrane peel, immediately post-epimacular membrane peel, and post-ILM peel revealed that ILM peeling was necessary to resolve retinal folds intraoperatively.
Intraoperative SD-OCT improvement was correlated with improvement in metamorphopsia, but not with visual acuity at 3 months.
Functional Outcome in Patients With Posterior Vitrectomy After Idopathic Epiretinal Membrane From 2007 to 2011
Presenter: Boris Bajaire, MD
This retrospective review of 82 cases of ERM treated with pars plana vitrectomy and membranectomy revealed improvement in 58 cases (average logMAR 0.6 pre-op, average logMAR 0.4 post-op), stabilization in 14 cases (average pre- and post-op logMAR 0.4), and worsening in 10 cases (average logMAR 0.4 pre-op, average logMAR 0.7 post-op). Recurrence of ERM was rare and occurred in 4 cases (4.8%).
Epiretinal Membrane Progression Occurs in Exudative Age-Related Macular Degeneration and May Contribute to Poorer Anatomical and Functional Outcomes
Presenter: Omar Punjabi, MD
In this retrospective study, 22 eyes receiving intravitreal anti-VEGF agents for exudative AMD demonstrated progression of ERM over 1 year regardless of PVD status or the number of injections.
Eyes with ERM had a lesser anatomic and functional response to anti-VEGF treatment compared to non-ERM eyes as evidenced by OCT thickness (change in ERM eyes -45 microns, change in non-ERM eyes -113 microns), visual acuity (decrease from 20/100 to 20/250 in ERM eyes, improvement from 20/100 to 20/80 in non-ERM eyes), and number of required injections (4.6 in ERM eyes, 4.1 in non-ERM eyes).
Natural Clinical Course of Unoperated Eyes With Vitreomacular Traction Syndrome
Presenter: Vishak John, MD
A classification system for vitreofoveal traction syndrome is proposed: Stage 1: no cysts, Stage 2: intraretinal cysts or clefts, and Stage 3: elevation of the neurosensory retina from the RPE. Twenty-three percent of eyes (12/51) with VFTS resolve spontaneously.
AMD IV Symposium
Wednesday, August 29, 9:30-10:00 AM
Moderators: Thomas Albini, MD, Anne Fung, MD
Reported by Mitchell J. Goff, MD
Salt Lake City, Utah
Vascularized Pigment Epithelial Detachment Treated With 0.5 mg versus 2 mg Ranibizumab: Analysis of Results Based on Lesion Subtypes
Presenter: Clement Chan, MD, FACS
In an exploratory analysis, both 0.5mg and 2.0 mg doses of ranibizumab administered monthly or PRN proved equally effective in terms of flattening both serous vascularized PED (87.5% flattened) and fibrovascular PED (53.6% flattened) at one year. There was a trend for more effective flattening of vascularized serous PED based on certain anatomic measures.
The number of injections was similar for both types of PED (8.2 for vascularized serous PED vs 9.4 for fibrovascular PED). Both doses reduced the chance of vision loss over 1 year.
Juxtapapillary Retinal Pigment Epithelial Detachments in Asymptomatic Subjects Detected With Spectral Domain Optical Coherence Tomography
Presenter: Alexander Walsh, MD
Using SD-OCT in asymptomatic, predominantly Hispanic patients, the prevalence of juxtapapillary retinal pigment epithelial detachment was found to be 48% and was not associated with the presence of peripapillary pigment or peripapillary atrophy. The authors suggest that they may be fibrovascular in nature due to their association with drusen and age.
A Phase 1 Study Targeting Tissue Factor with a Single Dose of Intravitreal hI-con1 for Exudative Age-Related Macular Degeneration (AMD)
Presenter: Christine Gonzales, MD
In a Phase 1 study, safety and biologic activity (regression of CNV, reduced OCT thickness, and improved vision) were demonstrated with intravitreal injection of hI-con1, a novel agent that binds tissue factor leading to natural killer cell destruction of abnormal vascular endothelial cells. There were no safety signals, specifically no cases of intraocular inflammation. A dose response curve was observed.
Argon Laser With and Without Anti-vascular Endothelial Growth Factor Therapy (VEGF) for Polypoidal Choroidal Vasculopathy
Presenter: Yew San Ian Yeo, MBBS, FRCS
Twenty-eight of 33 eyes with extrafoveal polypoidal vasculopathy demonstrated stable or improved vision at 1 year (mean gain of 7.5 letters) after laser ablation of active polyps. Few of these patients required subsequent VEGF medication (36.4% with a median of 2.5 injections).
Combination Therapy for Neovascular AMD Using PRN Ranibizumab and a Single Injection of Liquid Sustained-Release Intravitreal Triamcinolone Acetonide
Presenter: Jennifer Lim, MD
Using combination treatment with a single injection of a novel liquid sustained release (up to 12 months) system containing triamcinolone acetonide called "Verisome" plus ranibizumab PRN, only 14/74 potential retreatments with ranibizumab were required in 10 patients by month 12, suggesting a decreased treatment burden. The median retreatment rate was 2 through month 6 and 2 through month 12. Elevated IOP occurred in 8 of 10 patients and was controlled with drops alone.
Pediatric Retina Symposium
Wednesday, August 29, 10:00-10:48 AM
Moderators: Audina Berrocal, MD, FACS, G. Baker Hubbard, MD
Reported by J. Michael Jumper, MD
San Francisco, California
Fluorescein Angiographic Findings in Spontaneously Regressing Stage 1 or 2 Retinopathy of Prematurity
Presenter: Virgilio Morales-Canton, MD
RetCam photos and FA done on 20 infants with stage 1 and 2 ROP (zone II or III) which eventually regressed spontaneously. A total dose of 0.1 mg/kg of fluorescein sodium 10% solution was given. Selective cases had OCT performed.
Findings included:
- Areas of choroidal hypoperfusion and macular retinal hyperfluorescence without corresponding OCT findings.
- Vascular leakage near the demarcation line.
- Capillary nonperfusion, microaneurysms and vascular "sprouts" posterior to the demarcation line.
Safety and Efficacy of 137 Intravitreal Bevacizumab Injections Without Laser as Primary Therapy for ROP With 5 Years of Follow-up
Presenter: Alay Banker, MD
- One hundred thirty-seven eyes of 88 patients with threshold ROP with or without plus disease received intravitreal bevacizumab (0.625mg in 0.025mL). Eight (6%) eyes had persistent peripheral avascular retina.
- Anatomic outcome: regression of ROP after a single treatment. No laser performed in any, including the 8 (6%) eyes that had persistent peripheral avascular retina. OCT done at 5 years. No structural abnormalities.
- ERG/ VEP findings: normal in all eyes.
- Neurodevelopment evaluation performed by pediatric neurologist found to be with the normal range.
- Refractive outcomes of 58 eyes. No difference in the development of myopia in eyes who received bevacizumab, laser,or laser and bevacizumab (control groups).
- No adverse events reported that were felt to be due to the bevacizumab.
- Median Va 20/40, mentioned in the discussion.
Systemic and Ocular Adverse Events After 334 Injections of Intravitreal Bevacizumab in the Treatment of ROP: 5-Year Follow-up
Presenter: Maria Martinez-Castellanos, MD
In this large series, patients with treatment requiring ROP received one of 2 doses of bevacizumab (1.25 mg in 0.5 mL or 0.75 in 0.3 mL). These are larger babies born at later gestational ages than in developed countries.
- 4.5% had persistent avascular retina.
- 4/5 of those with Stage 4 ROP had progression of traction detachment requiring surgery and bevacizumab should not be used in this subset of patients.
- IOP elevation was an issue with the larger-volume injection.
- Median final vision was 20/30.
Late Complications of Non-enzymatic Vitrectomy in Infants
Presenter: Michael Trese, MD
Dr. Trese emphasized that all pediatric retinal vascular diseases are indeed vitreoretinopathies. Surgical separation of the posterior hyaloid by surgery alone is difficult, if not impossible in these cases.
While initial surgical results may be good (eg, for Stage 4 ROP), late vitreous separation and hyaloidal contraction can be a cause for late vision loss. Pharmacologic vitreolysis at the time of initial surgery may aid in preventing late vision loss.
Candida Lens Abscess in Premature Infants
Presenter: G. Hubbard, MD
Dr. Hubbard presented 3 cases of late presentation of endogenous fungal endophthalmitis in low birthweight infants who had fungemia while in the neonatal intensive care unit (NICU). An abscess of the lens was discovered 10, 21, and 54 weeks after discharge. Cultures of aqueous aspirates were negative while lens culture at the time of surgery found Candida sp. in all.
Vision outcomes were poor (light perception, counting fingers and no light perception). The presumed pathogenesis was lens penetration of the fungus via the tunica vasculosa lentis. Early recognition may help outcomes.
Digital Fluorescein Angiography-Guided Treatment for Pediatric Retinal Diseases
Presenter: Audina Berrocal, MD, FACS
Dr. Berrocal demonstrated the importance of wide-field angiography in guiding laser treatment for various pediatric retinal diseases including Coats and FEVR. It is especially good at detecting areas of capillary dropout in such cases.
Diabetic Retinopathy II Symposium
Wednesday, August 29, 10:48-11:14 AM
Moderators: G. Phillip Matthews, MD, and J. Michael Jumper, MD
Reported by J. Michael Jumper, MD
San Francisco, California
Outcomes of Pars Plana Vitrectomy for Tractional Retinal Detachment Secondary to Proliferative Diabetic Retinopathy
Presenter: Elliott H. Sohn, MD
Dr. Sohn reported 10-year data on 240 eyes from 203 patients. Twelve percent of patients had a combined traction/rhegmatogenous retinal detachment; 6.3% of patients required reoperation, and 1.3% required enucleation. Of those with preoperative visual acuity of 20/70 or better, 75%-80% had stable vision with few improving.
Of those with preop vision of 20/80 or worse, ~60% had improvement, likely due to the presence of vitreous hemorrhage in this group. Of the 215 phakic patients, 36% required cataract extraction.
Diabetic Retinopathy Lesions and Photoreceptor Mosaic Changes as Assessed with Ultrahigh Resolution Adaptive Optics Scanning Laser Ophthalmoscopy
Presenter: Jennifer K. Sun, MD
Dr. Sun reported findings of AOSLO with resolution on the order of 2 micrometers. Acquisition times range from 15 minutes to 1 hour depending on the area of study. Changes to photoreceptor density and the area occupied by photoreceptors were seen in subjects with diabetic macular edema.
Instrumentation/Pharmacology Symposium
Wednesday, August 29, 11:14-11:50 am
Moderators: G. Phillip Matthews, MD, PhD, J. Michael M Jumper, MD
Reported by Thomas Aaberg Jr, MD
Grand Rapids, Michigan
A Small-Gauge Fragmatome and Method for Removal of Retained Lens Fragments
Presenter: William Foster, MD
Dr. Foster has developed and patented a small-gauge fragmentation probe capable of fragmenting lens nucleus via a 25-gauge trocar.
The unit does not have aspiration capabilities, but will fragment lens material, enabling extraction with the vitrectomy cutter.
Pilot Evaluation of a New Portable Small-Gauge Vitrectomy Unit
Presenter: Thomas Aaberg Jr, MD
Dr. Aaberg introduced a portable compact small-gauge vitrectomy unit, the VersaVit manufactured by Synergetics. Seven patients underwent vitrectomy surgery using the prototype unit with good outcomes and no complications. The author concluded that the unit is safe, effective, and provides vitreoretinal surgeons with a low-cost alternative vitrectomy unit.
Benefit of Direct-View for Submacular Surgery
Presenter: Zhizhong Ma, MD
Dr. Ma discussed the potential advantages of large retinotomy and reflection of the macular retina for submacular surgery. The author argued that direct visualization of the choroidal neovascular membrane and surrounding structures results in less morbidity to the neuroretinal macular region and underlying retinal pigment epithelium. Electron microscopy was used to assess whether RPE was attached to the CNV. According to Dr. Ma, the removed cnv complex was devoid of RPE.
Electronic Reading Devices Increase Reading Speed and Comfort in Patients With Moderate Vision Loss
Presenter: Daniel Roth, MD
This study demonstrated that for visually impaired individuals, there was a statistically significant improvement in reading speed and comfort using an iPad with back illumination and enlarged font compared to a Kindle or a book.
Initial Experience With Oral Rifampin for Treatment of Central Serous Chorioretinopathy
Presenter: Zac Ravage, MD
Oral rifampin was found to have an apparent therapeutic effect on patients with central serous chorioretinopathy. The author used a dose of 300-600 mg daily until fluid resolved, then discontinued or tapered the drug. Liver function enzymes were checked prior to initiating rifampin then every 3 months thereafter while drug was still being used.
Early Detection of Functional Changes Using Microperimetry on Patients With Subclinical Hydroxychloroquine Toxicity
Presenter: Clement Chow, MD
Microperimetry with the OPKO spectral OCT/SLO microperimeter was used to assess macular function in 16 patients taking plaquenil for 5 years and compared to 10 controls. Mean sensitivity was statistically significantly lower in plaquenil patients when compared to controls particularly in perifoveal region. There was no corresponding difference in OCT thickness.
Posters
Reported by Michael A. Singer, MD
San Antonio, Texas
Retinal Vascular Disease
403: Three mm and 6 mm quadrant on OCT more sensitive than central field thickness for indicators of disease progression.
Imaging--Digital--Angiography
408: Can adjust spectral-domain OCT to approach thickness of time-domain OCT.
414: OCT of the angle may predict severe steroid responders prior to intravitreal injection.
418: Oxymap shows higher oxygen saturation in PDR eyes compared to controls.
420: Mean macular thickness Spectralis and Stratus varies by gender in patients with diabetes
Pediatric Retina--ROP
605: FA may show macular changes in prethreshold ROP not seen clinically
Pharmacology
803: Postoperative steroid responder glaucoma lower in psuedophakic patients than phakic patients after PPV.
805: Instant increase in IOP does not cause significant decrease in retinal blood flow after intravitreal injection.
Retina Times thanks all who attended the 30th ASRS Annual Meeting. We hope you found the symposia and instructional courses interesting and relevant to your practice.