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ISSUE

posterior segment • innovation • enlightenment

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PIE M A G A ZINE ’ S D A ILY CONGR E S S NE W S ON T HE P O S T E RIOR S E GME N T

HIGHLIGHTS out the 04 Check universal guidelines

for the management of DME

the 08 Behold vitreoretinal surgeons’ nightmares!

Eyes — How 11 Fragile ophthalmologists

treat eye diseases in premature babies

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T

he 8th session in this year’s EURETINA virtual conference has, in the words of its co-chair, Dr. Ursula Schmidt-Erfurth, become something of a good tradition, as it represents the guidelines for the future of managing retinal diseases. Each year, this forum focuses on new technologies and methodologies being applied in retinal treatments, in what it terms “The Next Steps”.

Taking the next steps with AI This year, the forum is dedicated to discussing one of the biggest terms being heard all around the conference: artificial intelligence (AI). AI is playing an ever-growing role in how retinal conditions are being identified, tracked, and diagnosed, and it makes perfect sense that it takes center stage in the discussion of the next steps forward. “We always claimed that this is about the next steps, and it always is,” said Dr. Schmidt-

Erfurth. “So this year, we do have a focus on artificial intelligence, which is not only a next step, but also a horizon.” For, indeed, though the nascent applications of AI are already teaching us things about disease progressions that have never been detectable in the past, we are still at the very beginning of exploring its applications.

AI in AMD Treatment — What’s New? One of the areas in which AI has been of such tremendous benefit is its use in the analysis of color fundus photographs (CFP). Beginning the discussion of this topic, Dr. Caroline Klaver presented the ways in which AI-assisted CFP is useful in treating age-related macular degeneration (AMD). There are two primary levels in which this technology has begun to make an impact here. >> continued on Page 3


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11 September 2021 | Issue #2

The 14th APVRS Congress Virtual

December 11 - 12, 2021

OZURDEX® acts fast1,2 and lasts3–5 with less treatment visits compared with anti-VEGFs,5 making it the enduring partner you need. Effective DME treatment doesn’t have to be a burden.6

2021

v i r t u a I

The most commonly reported adverse events reported following treatment with OZURDEX® are those frequently observed with ophthalmic steroid treatment or intravitreal injections (elevated IOP, cataract formation and conjunctival or vitreal haemorrhage respectively). Less frequently reported, but more serious, adverse reactions include endophthalmitis, necrotizing retinitis, retinal detachment and retinal tear. Licences may vary by country, please refer to your local country SmPC. DME, diabetic macular edema; IOP, intraocular pressure; VEGF, vascular endothelial growth factor. 1. Lo Giudice G et al. Eur J Ophthalmol 2018;28(1):74–79. 2. Veritti D et al. Ophthalmologica 2017;238(1–2):100–105. 3. Escobar-Barranco JJ et al. Ophthalmologica 2015;233(3–4):176–185. 4. Allergan. OZURDEX® Summary of Product Characteristics. 5. Kodjikian L et al. Biomed Res Int 2018:8289253. 6. Boyer DS et al. Ophthalmology 2014;121:(10):1904–1914.

ORGANIZER:

INDICATIONS & USAGE: OZURDEX® contains a corticosteroid indicated for the treatment of macular edema following branch retinal vein occlusion (BRVO) or central retinal vein occlusion (CRVO), for the treatment of non-infectious uveitis affecting the posterior segment of the eye, and for the treatment of patients with visual impairment due to diabetic macular edema (DME) who are pseudophakic or who are considered insufficiently responsive to, or unsuitable for non-corticosteroid therapy. DOSAGE & ADMINISTRATION: For ophthalmic intravitreal injection only. The intravitreal injection procedure should be carried out under controlled aseptic conditions. Following the intravitreal injection, patients should be monitored for elevation in intraocular pressure and for endophthalmitis. DOSAGE FORMS & STRENGTHS: Intravitreal implant containing dexamethasone 0.7 mg in the NOVADUR™ solid polymer drug delivery system. CONTRAINDICATIONS: Ocular or periocular infections. Advanced glaucoma. Aphakic eyes with ruptured posterior lens capsule. Eyes with ACIOL, iris or transscleral fixated IOLs and rupture of the

FIND US ON:

Licenses may vary by country, please consult your local Summary of Product ASIA-PACIFIC VITREO-RETINA SOCIETY

posterior lens capsule. Hypersensitivity. WARNINGS AND PRECAUTIONS: Intravitreal injections have been associated with endophthalmitis, eye inflammation, increased intraocular pressure, retinal detachments, and implant migration into the anterior chamber. Patients should be monitored following the injection. Patients who has a tear in the posterior lens capsule (e.g., due to cataract surgery), or who had an iris opening to the vitreous cavity (e.g., due to iridectomy) are at risk of implant migration into the anterior chamber. Use of corticosteroids may produce posterior subcapsular cataracts, increased intraocular pressure, glaucoma, and may enhance establishment of secondary ocular infections due to bacteria, fungi, or virus. Corticosteroids should be used cautiously in patients with a history of ocular herpes simplex. ADVERSE REACTIONS: In controlled studies, the most common adverse reactions reported by 20–70% of patients were cataract, increased intraocular pressure and conjunctival haemorrhage.

2021.apvrs.org

APVRS

Characteristics. Adverse events should be reported to your Ministry of Health and local Allergan office. JOB CODE: INT-OZU-2050218 DATE OF PREPARATION: NOVEMBER 2020

OZURDEX® is not licensed for use in DME in China.

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APVRS


PIE magazine’s Daily Congress News on the Posterior Segment

>> continued from Page 1

At the image level, CFP can give us a broad basis of predictive comparison using AI, which is useful for diagnostic and referral support. Looking a bit deeper, however, it is also highly effective at charting the condition’s development at the lesion level, where we are able to achieve a much more sophisticated quantification of the biomarkers that characterize AMD, such as drusen. The grading of CFP at the lesion level requires a substantial amount of time, and that time must be spent by a highly qualified and experienced professional. By optimizing the grading of the extent of biomarkers through expert human grading in conjunction with algorithmbased AI modeling, we can achieve consensus grading that yields a far more accurate result than either could have done alone. This can lead to constructing a far more effective regimen of treatment and of slowing the progression of AMD. In addition to diagnosis and assessment, AI technology also has a place in treating AMD. Co-chair Dr. Anat Lowenstein presented additional findings on the efficacy of AI in AMD treatment from a research project utilizing optical coherence tomography (OCT) devices, which patients can use in their own homes. These devices employ AI algorithms that automatically identify and quantify fluid volume in patients’ eyes, generating results that are sent to physicians. Such devices can employ nuanced analyses that can save a lot of discomfort and difficulty for patients, as well as saving time for both the patient and their ophthalmologist.

Diagnosing diabetes-related eye diseases and other conditions Venturing into other areas of retinal care where AI has been making a profound impact, Dr. Ramin Tadayoni then presented on the area of diabetic retinal/ macular disease. Here, too, the utility has involved CFP imaging in order to identify warning signs of illness and provide avenues for treatment. As this disease is so prevalent, affecting over one hundred million people worldwide, and demands a very long course of therapy to treat, it simply requires enormous amounts

of human resources which are simply unavailable. The solution to this, according to Dr. Tadayoni, is that of computer systems capable of performing tasks normally requiring human intelligence, and perhaps proving themselves even more capable in those specific capacities. While the biomarkers indicating the presence and extent of diabetic retinopathy (DR) and diabetic macular edema (DME) differ from those signifying AMD, the same applications of AI-assisted CFP are useful in its diagnosis. Similarly, as fluid levels in the eye are of concern in this area of treatment as well, at-home “smart” OCT devices could be of enormous benefit to those with diabetes-related vision diseases.

Looking beyond the retina While previous speakers made an undeniably strong case for the use of AIassisted CFP in diagnosing retinal disease, the next presenter, Dr. Tien Wong, showed that this advanced algorithmic technology can be used to identify numerous problems beyond the eye. While the signs of diabetes often manifest in the retina, as Dr. Tadayoni had discussed, it is not usually through optical examinations that this condition is discovered. And, of course, the effects of diabetes are more far-reaching than those concerning a patient’s vision. Most of the time, a diabetic patient would already be aware of their condition and would be seeking CFP diagnoses for the potential threats that diabetes can have to their vision. But diabetes is far from the only disease which AI-assisted CFP can reveal. In fact, it can be used to detect a wide array of highly threatening diseases, often in a less

invasive manner than those traditionally used to detect these diseases. For example, through the use of CFP with AI that has been programmed to consider factors such as age, blood pressure, and body-mass index, Dr. Wong said it could prove as effective as a carotid ultrasound or CT scan in detecting a patient’s risk of stroke or other cardiovascular diseases. This is possible because of the process of “deep learning” intrinsic in AI. The systems which can establish correlations between certain specified criteria are not necessarily limited to those criteria. Thus, when the AI is instructed to analyze the complete arterial structure within the eye, rather than just those arterial deformations that indicate DR/DME, it is capable of discovering more about the patient’s overall cardiovascular health. From this point in the analysis, the possibilities for further diagnoses only grow. Dr. Wong presented evidence suggesting that AI-assisted CFP could, when provided with appropriate instructional data sets, be used to detect even more diverse diseases, such as chronic kidney disease or anemia. By analyzing patterns in widespread axonal degeneration in optic nerves in Alzheimer’s disease patients, CFP could be used for early diagnosis of this condition in the future as well.

A bright future ahead, indeed While this world of possibilities in diagnostic research is ever-expanding, Dr. Wong pointed out that it is only just beginning and in the research rather than the clinical phase of its potential uses. Thus, while all of the findings presented in this forum are extremely exciting, some are eagerly awaited next steps, while others are still on the horizon.

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In Pursuit of Harmony Universal guidelines for the management of diabetic macular edema

by Olawale Salami

F

inding the best treatments to recommend within national and global treatment guidelines requires using systematic methods of consensusbuilding that rely on empirical evidence. In his presentation at the EURETINA 2021 Virtual, Prof. Laurent Kodjikian of the Department of Ophthalmology, Croix Rousse University Hospital, Lyon, France, shared that the Delphi methodology for consensus development is quite popular globally. It requires the categorization of stakeholders into two groups. “The first group, the steering committee, in our case, consists of four to six healthcare providers who are representative of daily

practice and able to define the relevance of published studies and different clinical situations evaluated,” Prof. Kodjikian explained. “The second group, known as the rating group, comprises about 25 to 30 professionals working daily with those affected by the recommendations, for example, physicians or ophthalmologists who treat patients with retinal disorders daily.” Prof. Kodjikian emphasized the importance of ensuring independence between the steering committee, which formulates the proposals, and the rating group, which judges the appropriateness of the submitted proposals.

Reaching a general consensus Eight existing international consensus guidelines on diabetic macular edema (DME) management have produced recommendations utilizing the Delphi methodology, and Prof. Kodjikian presented a summary of these. These are the EURETINA guidelines, the French Delphi, the international algorithm published in the European Journal of Ophthalmology, the German Consensus, the Italian Consensus, the Spanish the UK consensus, and the Asian-Pacific consensus.


PIE magazine’s Daily Congress News on the Posterior Segment

“Firstly, we observed that all eight international guidelines reached a consensus on the involvement of inflammation in the pathogenesis of DME,” Prof. Kodjikian shared. “In addition, a consensus was reached by the Italian, German, French, and Spanish Delphi guideline groups on the anti-angiogenic and anti-inflammatory properties of dexamethasone. This is important given the central role of inflammation in the pathogenesis of diabetic retinopathy, especially the involvement of glial cells in driving inflammatory cascades early in the disease,” he explained. Prof. Kodjikian also noted: “This is the real advantage offered by dexamethasone implant because, aside from its antivascular endothelial growth factor (anti-VEGF) role, dexamethasone induces a strong anti-inflammatory role against different cytokines involved in the pathophysiology of diabetic retinopathy and DME.” During the presentation, Dr. Anat Loewenstein, a retina specialist from Tel Aviv, Israel, posed the question: Are the results with Ozurdex (Allergan, Dublin, Ireland) in suitable naïve patients the same in patients treated at a later disease stage? “Early treatment in suitable naïve patients with Ozurdex always results in better final visual acuity,” replied Prof. Kodjikian. “And when anti-VEGF-based first-line treatments are not efficacious, it is advisable to switch very early to Ozurdex.”

Effective first-line DME treatment in patients with poor compliance Seven of the eight guidelines reviewed concluded that Ozurdex could be considered for first-line treatment of suitable DME patients with poor compliance. Providing an efficacious option for patients is essential because real-life evidence shows that optimal outcomes with anti-VEGF therapies require about eight to nine injections in the first year. In addition, the EURETINA guidelines state that corticosteroids are recommended in patients who are unable to receive monthly injections in the first six months of therapy. However, intraocular pressure (IOP) of these patients still requires regular monitoring. Overall, with Ozurdex, patients

experience less treatment burden with fewer intravitreal injections compared to anti VEGF. Thus, fewer clinic visits and better adherence. Prof. Kodjikian explained further: “A complete consensus was reached across all eight guidelines that Ozurdex can be used as first-line therapy for DME pseudophakic patients. The MEAD phase 3 study evaluated the safety and efficacy of the Ozurdex implant. It showed a mean best-corrected visual acuity (BCVA) improvement from baseline in pseudophakic eyes of +6.5 letters versus +1.7 letters in the placebo group after 36 months.”

A hallmark of safety in subpopulations of patients According to Prof. Kodjikian, “In patients scheduled for cataract surgery, Ozurdex permits excellent control of DME during surgery with no worsening after surgery and no delay in visual recovery. The consensus is that Ozurdex can be considered in suitable patients with DME who are candidates for cataract surgery.” Topical IOP-lowering treatment is sufficient to control the IOP elevation induced by Ozurdex in most cases. This consensus was reached in five national guidelines and supported by data from the clinical studies. IOP monitoring is mandatory between one and two months after each of the first two Ozurdex injections. Ozurdex is indicated as both first-line and second-line treatment of DME, and efficacy is demonstrated based on noninferiority in interventional studies. In observational, real-life studies, Ozurdex demonstrated better outcomes compared to anti-VEGF therapies. It is effective and has a rapid onset of action with a duration

“Overall, with Ozurdex, patients experience less treatment burden, with fewer intravitreal injections compared to anti VEGF. Thus, fewer clinic visits and better adherence.”

of efficacy of up to 6 months. Side effects are generally predictable, transient, and manageable. Raised IOP is rarer in DME than in other indications, and topical treatment alone is sufficient in 97% of cases.

Predicting treatment outcomes in DME Can we have one treatment for all patients with DME, or is there room for individualized treatments? How should these treatments be selected? These questions were raised by Prof. Zavier Ventura, Institut Clinic d’Oftalmologia, Barcelona, Spain, during the conference. Prof. Ventura provided additional insights into this vital subject. “DME treatment requires an individualized approach, and several factors require consideration in selecting the best treatment for patients,” he shared. “These factors include treatment history (naïve vs. previously treated) phakic status of the eye, IOP status, and the presence of cardiovascular risk factors. In addition, social factors that determine patients’ ability to comply with frequent clinic visits for intravitreal injections need to be evaluated. This is especially important in the light of the COVID-19 pandemic, where there is a trend towards a reduction in the frequency of clinic visits.” Prof. Ventura added: “We and others have shown that treatment with dexamethasone implants provide better suppression of a wide variety of inflammatory cytokines which may, in part, explain the differential responses seen in patients. In addition, both suitable naïve eyes and those previously treated show significant sustained gains in visual acuity following treatment with Ozurdex. Importantly, suitable naïve eyes required significantly lower number of injections compared to previously treated eyes.” Anatomical biomarkers are central to the understanding of disease pathways and selecting the best treatment. “As we look into the future of treating naïve and treatment-experienced patients, we hypothesize that optical coherence tomography (OCT) and other imaging tools could help delineate anatomical patterns and predict even better response to treatment,” noted Prof. Ventura.

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can be used for planning combination therapy,” shared Dr. Lai. “ICGA remains the gold standard for the diagnosis of PCV and is still recommended when planning for combination therapy.

Managing subretinal hemorrhage due to PCV Prof. Andrew Chang from Sydney, Australia, on the other hand, shared his experience on the surgical management of subretinal bleed due to PCV.

Vantage Point

Insights on polypoidal choroidal vasculopathy by Tan Sher Lynn

P

olypoidal choroidal vasculopathy (PCV) primarily affects the vascular layer of blood vessels in the choroid, resulting in damage to the overlying retina. On the second day of the EURETINA 2021 Virtual, experts shared their thoughts on diagnosing PCV and treating subretinal bleeding caused by PCV.

Differences in choroidal background matter “PCV can occur over a variety of background, such as over the nevus or the edge of staphyloma, or it can present itself as an aneurysmal lesion developing out of chronic type 1 macular neovascularization,” shared Prof. Gemmy Cheung from the Singapore National Eye Centre. “In Asians, there may be more eyes developing changes as a result of being pachychoroid- and drusen-driven. Those with pachychoroid-driven background tend to present with typical PCV, while those with drusen-driven background tend to present with type 1 macular

neovascularization,” she continued, noting that differences in choroidal background may help mitigate differences in sub-phenotypes and drusen/ pachydrusen background. According to Prof. Cheung, choroidal venous overload results in remodeling and intervortex venous anastomoses. “Photodynamic therapy (PDT) temporarily reduces choroidal hyperpermeability, but pachyvessels may not be reversible,” she said. “Evidence related to the influence of choroidal background on treatment responsiveness to anti-vascular endothelial growth factor (anti-VEGF) therapy remains inconsistent.” Meanwhile, Dr. Timothy Lai from the Chinese University of Hong Kong, China, said that in routine clinical practice, non-indocyanine green angiography (ICGA) diagnostic features such as fundus appearance and spectral domain optical coherence tomography (SDOCT) signs can often establish the diagnosis of PCV. “SDOCT is useful in determining the activity of PCV in diagnosing PCV following anti-VEGF monotherapy and

He noted that PCV subretinal bleed can lead to devastating and permanent visual loss as well as subretinal fibrous scarring. “We have a number of tools that can manage a submacular hemorrhage, including gas, intravitreal or subretinal injection of tissue plasminogen activator (tPA), vitrectomy, anti-VEGF, as well as thermal laser and PDT laser. The options depend on the vision of the patient, their ability to position, and the extent and location of the blood,” Prof. Chang explained. He shared a case involving a 62-yearold Chinese man who presented with an extrafoveal polyp and was treated with thermal laser ablation. The patient developed a reoccurrence of the polyp close to the fovea and was treated with PDT. Two weeks later, he had a sudden loss of vision due to a submacular hemorrhage. A pneumatic displacement of C3F8 gas was performed in an attempt to disperse the blood away from the fovea. Unfortunately, a week later, the patient reported a further loss of vision as blood has entered into the vitreous, and two weeks later, the bleeding worsened. Drainage was considered for the patient. Heavy liquid was used to displace the blood, a peripheral retinotomy was performed, and the hemorrhage and exudation were removed. “Subretinal bleeding may cause devastating vision loss. In my practice, I use intravitreal gas injection as the first line of treatment, and consider vitrectomy surgery in selected cases,” Prof. Chang shared. “Heavy liquid is a useful adjunct to drain blood through the peripheral retinotomy. These patients require ongoing treatment with anti-VEGF therapy and possibly PDT,” he concluded.


PIE magazine’s Daily Congress News on the Posterior Segment

They did the mash — They did the macula mash Behold the vitreoretinal surgeons’ nightmares! by Elisa DeMartino

P

arodying the chorus line from Bobby Pickett’s 1962 hit “Monster Mash” might induce slightly exaggerated mental images of what happens in vitreoretinal surgery. Certainly nothing is getting mashed (we hope!), but EURETINA 2021 Day 2’s Symposium Session demonstrated that nightmares aren’t just for sleep! With Halloween just lurking around the corner, it’s a good time to discuss surprise spooks that can go “boo!” during an operation.

Submacular hemorrhage during surgery Dr. Lars-Olof Hattenbach from Augenklinik des Klinikums in Ludwigshafen, Germany, was working in the lab late one night… when his eyes beheld an eerie sight… a submacular hemorrhage during vitrectomy for retinal detachment! Though rare, hemorrhaging during or after an operation may be triggered by several risk factors, such as anticoagulant agents, age, and poor general health status. Dr. Hattenbach demonstrated examples of such an event in two elderly females who had successful reattachment despite the hiccup.

He reported that prompt though not too aggressive removal of blood and successful retinal reattachment provide excellent chances for visual recovery. So there’s no need to panic in this situation.

Subretinal displacement of infusion cannula Royal Liverpool University’s Dr. Heinrich Heimann introduced chilling scenarios where the infusion cannula is not in position, causing subretinal or suprachoroidal displacement of infusion cannula. This in turn results in choroidal detachment or choroidal hemorrhaging. The number one way to prevent this is by anticipation: keep low intraocular pressure (IOP), verify the infusion is through the ciliary epithelium in EVERY case with no exception, and never open the infusion without verification of the correct position. What if you can’t see the infusion? “NEVER turn infusion on before you see the infusion port,” Dr. Heimann warned. There’s a short window of opportunity to recognize a subretinal displacement once

Risk factors are like shadows, warning of a possible complication.

it happens. “Usually you feel something is not right,” he said. Loss of red reflex, a hard eyeball, or a cutter not working are all examples of this. Develop a reflex when these symptoms start, Dr. Heimann instructed, to check the infusion, turn it off, and make sure it’s in the right place.

Uncontrolled bleeding during diabetic vitrectomy Dr. Bhuvan Chanana, vitreoretinal head at Bharti Eye Hospital Foundation in India, talked about uncontrolled bleeding during diabetic vitrectomies and how to manage it with a step-by-step approach. For cases of mild bleeding, Dr. Chanana recommends localizing and cauterizing the bleeding using a bimanual approach with active aspiration and coagulation with a diathermy laser. His preference is to begin by cutting the hyaloid around 360 degrees — starting from the optic nerve, he cautioned, increases the chances of severe hemorrhage. If bleeding is heavier or persistent, practitioners should consider postponing surgery and administering an antivascular endothelial growth factor (antiVEGF) therapy. They might also close with an injection of silicone oil using heavy liquids, or perfluorocarbon heavy liquid (PFCL). The PFCL can be left inside the eye for persistent bleeding as a temporary tamponade, and reoperation can be carried out after three to five days. Armed with all this knowledge, it’s safe to say we can sleep at night nightmare-free. The techniques of these experts will, as the song goes, catch on in a flash.

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The Underrated Choroid Experts share groundbreaking findings in managing choroid disorders

by Tan Sher Lynn

F

rom supplying the outer retina with nutrients to maintaining the temperature and volume of the eye, the choroid has many underrated functions. And it’s about time we dedicated a session to this important yet lesser-known part of the eye. On the second day of the EURETINA 2021 Virtual, leading scientists did exactly that. They shared their latest discoveries in the management of choroid disorders as well as advancements in technology to diagnose these conditions.

Innovations in choroidal imaging The first speaker was Prof. Shozo Sonoda of the Kagoshima University Hospital, Ja-pan, who talked about “Advancements in Choroidal Image”, noting that Optos fundus images cannot be used to visualize the entire vortex vein. To solve this problem, Prof. Shozo Sonoda and his teammates capture the Optos fundus images in both upward and downward views so that extreme peripheral fundus images can be recorded. They also made non-invasive observation of the entire cortex vein possible by creating a combined image to observe the periphery of the choroid. Quantification using a 3D eye model also overcomes the weaknesses of two-dimensional measurement and is more accurate. “In pachychoroid eyes, differences in distance and angle are observed only in the up-per half of the fundus,” observed Prof. Sonoda. “Position of the temporal

upper vortex vein shifted in the vertical direction of the eyeball and the distance was increased.” He added that the distance on the nasal upper vortex vein did not change, but a corresponding shift was observed at the temporal upper side. “Deviation of the upper temporal vortex vein to the direction of hydrodynamic load is likely to trigger congestion due to gravity. Since the same tendency is observed in the fellow eye of pachychoroid disease, the abnormal position of vortex vein may be the indirect aggravating factor,” Prof. Sonoda shared.

Is CSC a scleral disease?

Nevertheless, ‘pachysclera’ seems to contribute to the pathogenesis of CSC.”

Choroidal venous insufficiency in pachychoroid disease Meanwhile, Dr. K. Bailey Freund from the Vitreous Retina Macula Consultants of New York, USA, presented results from his analysis, which show that ultrawidefield indocyanine green angiography (UW ICGA) reveals patterns of choroidal venous insufficiency influencing pachychoroid disease.

According to Dr. Hideki Koizumi of the University of Ryukyus, Japan, central serous chorioretinopathy (CSC) is observed with dilated choroidal vessels and choroidal vascular hyperpermeability on indocyanine green angiography (ICGA) and a thickened choroid on optical coherence tomography (OCT). The risk factors of CSC include stress, steroid use, type A personality, being male, and a genetic predisposition to the disease.

“UW ICGA shows choroidal venous insufficiency in eyes with pachychoroid disease relates to an imbalance in choroidal venous drainage,” Dr. Freund shared. “Congestion of one or more vortex vein systems is associated with regional choroidal thicken-ing, choroidal venous hyperpermeability (CVH), and remodeling of venous drainage routes. Sites of CVH in the macular region were usually located in areas showing the greatest choroidal thickness, or at the margin of these areas,” he added.

Dr. Koizume said they hypothesize that scleral abnormalities may cause vortex vein congestion and choroidal circulatory disturbances. “In addition, scleral thickening and decreased transscleral flow may be contributed to the disease as well,” noted Dr. Koi-zumi. “The limitation is, scleral thickness is measured under the rectus muscles and the anatomic features of the sclera surrounding the vortex veins remain unknown.

He and his teammates did an analysis comparing UW ICGA studies of 32 eyes with pachychoroid disease to 26 healthy controls. “Wide-field foveacentered swept-source optical coherence tomography (SS-OCTA) volume scans showed that 19 (59%) of them demonstrated asymmetric choroidal venous drainage of the macular region, with a dominance of a single vortex vein,” Dr. Freund concluded.


PIE magazine’s Daily Congress News on the Posterior Segment

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11 September 2021 | Issue #2

other hand, presented a case of retinal detachment with anterior proliferative vitreoretinopathy (PVR), which was very extensive on the temporal side.

RETINAWS at a Glance

A rundown on everything you need to know during the sessions by Olawale Salami

W

e get it, virtual conferences are convenient — jumping from one session to the other at the click of a mouse. The downside? Something’s gotta give and you would most likely miss important information while session hopping. Well, fret not. We’re here to give you a lowdown on things you might’ve missed during important RETINAWS sessions.

Treading cautiously in eyes with endophthalmitis Dr. Jose Garcia Arumi from the Instituto de Microcirurgia Ocular, Universidad Autonoma, Barcelona, Spain, presented a case of endophthalmitis after intravitreal injection. “Removal of the lens was difficult because of a very cloudy cornea, and we had to use an accessory light to visualize and dissect over the retina,” shared Dr. Arumi. “The process of dissection and vitrectomy, however, resulted in bleeding due to the acutely inflamed tissues. He added that after removing the remnants of the lens capsule, fluid air exchange was done, with antibiotics and silicone oil placed in the vitreous cavity. “Imaging revealed an atrophic appearance of the retina. The results were good with 20/200 final visual acuity in the patient,” he noted. “With silicone

oil, I recommend reducing the antibiotic dose by half because the meniscus between the silicone oil and retina is small. Hence, a need to reduce the dose.”

Posterior retinal adhesions in Stickler syndrome Meanwhile, in his presentation, Dr. Stratos Gotzaridis from Athens, Greece, shared that he had a case of a 15-yearold boy who had lost his contralateral eye following Stickler syndrome. “During surgery, we discovered that the eye already had 360 degrees prophylactic laser treatment,” said Dr. Gotzaridis. “There were multiple retinal breaks next to the old laser scars with severe adherence of the posterior vitreous with the retina.” He admitted that treating these adhesions can be difficult. “A total posterior vitreous detachment was created and then we added a buckle to prevent any future breaks in the retina. The visual acuity increased to 3/10, and the patient was quite satisfied,” he concluded.

Preventing subretinal perfluoron Dr. Manish Nagpal from Retina Foundation, Ahmedabad, India, on the

“After dissection, I decided to perform a retinectomy on the temporal side. Once this was done, I added perfluorocarbon and tried to peel off the remaining membranes,” Dr. Nagpal shared. “This was not successful due to traction, and I had to remove all the subretinal perfluorocarbon and proceeded with a 360-degree retinectomy due to the persistent contraction. Subsequently, I re-installed the perfluorocarbon, and at six months, I removed the silicone oil with the patient’s vision retained at 6/36.”

Handling frustrating macular folds We all know that macular folds can be complicated to handle surgically. Dr. Grazia Pertile of the Sacro Cuore Hospital, Verona, Italy, shared a case of a macular fold on the fovea. “First, I detached the retina and injected balanced sodium solution (BSS) with a 41G needle, avoiding creating a macular hole,” said Dr. Pertile “I then performed a peripheral break to drain the fluid and carefully flattened the retina. Internal limiting membrane (ILM) peeling was done at the end because doing this earlier may result in a macular hole. I always recommend delaying the ILM peeling in cases like this.”

Chasing the free ILM flap Last but not least, Dr. Ehab El Reyes from The Retina clinic, Cairo, Egypt, presented a case of refractory macular hole, previously operated on and now presenting as a flap-open macular hole. “We explored residual ILM flaps that could be utilized to close it. After this, I injected perfluorocarbon and tried to slide the flap into the macular hole,” shared Dr. Reyes. “This was done carefully to prevent dislodgement of the flap. Finding a missing ILM flap can be very difficult. And the most important thing to remember is always to place the flap under perfluorocarbon to stabilize it and prevent it from dislodgement,” he concluded.


PIE magazine’s Daily Congress News on the Posterior Segment

tests are often impossible with such patients. Thus, according to Dr. Parrozzani, we must focus largely upon results obtained from routinely tested blood parameters. Here, the aim is to identify correlations between the patient and others with ROP diagnoses in a premature population. But what would these correlations be?

Identifying retinal disorders in premature infants

Fragile Eyes Tackling the challenging task of treating eye diseases in premature babies

by Nick Eustice

O

ur 10th symposium session on the 2nd day of the EURETINA 2021 Virtual dealt with the unique challenges posed by retina conditions in children. As is the case in all areas of medical care, children require special considerations. However, this is an especially important issue in ophthalmology, as there are few things so fragile as a child’s eyes. The panel spoke on several diverse areas highlighting the various challenges faced when treating younger patients.

Premature babies and eye diseases The first panelist, Dr. Raffaele Parrozzani, spoke on the challenges that come with treating the most delicate patients of all: prematurely-born infants. As premature babies suffer from an increased likelihood of all manner of illnesses due to their early exit from the womb, it follows that their typically under-developed eyes also have an increased risk for great many retinal issues.

Considered generally, retinopathy of prematurity (ROP) is one of the major causes of preventable childhood blindness worldwide. The cause of this is the infant’s premature birth itself, with low gestational age and low birth weight being leading factors contributing to the condition, with more extreme conditions leading to a greater likelihood of instances of ROP.

Difficulty in diagnosis While premature infants are in greater danger of developing retinal defects, at the same time, they are also substantially more difficult to diagnose. Biomarkers indicating various conditions are difficult to obtain, due to the extreme fragility of the patients and their heightened occurrence of comorbidities. Often, these premature patients’ lives are in jeopardy at such times when the most effective steps can be taken to preserve their eyesight. For this reason, even the most rudimentary ophthalmological diagnostic

A non-interventional study conducted between 2012 and 2018 on a sampling of the earliest post-birth blood of 527 preterm infants aimed to answer that question. The study revealed a significant correlation between thrombocytopenic infants, or infants whose platelet count was substantially below average (<100 x 109/l), and severe ROP. In offering an explanation for why this might be the case, Dr. Parrozzani provided an interesting hypothesis. At the birth of the patient, being the first phase of ROP, platelets may have a more stimulating function in the development of new blood vessels, or angiogenesis, by delivering insulin-like growth factor hormones (IGF-1). As a result of this, a low platelet count has the potential to cause an imbalance between regulation mediators. Alternatively, this correlation could be explained during the second phase of ROP. Later on in the infant’s early development, during the vascularization phases within the eye, platelets may play a “scavenger” role in the perfused retina, by removing vascular endothelial growth factor (VEGF) proteins. This, Dr. Parrozzani said, could also be an explanation of this relationship between severe ROP and a low platelet count in the blood, due to the lack of “scavenger” platelets creating an excess of VEGF. Whatever the cause of this relationship between platelet levels and ROP may be, Dr. Parrozzani said that this data, obtainable through a simple blood test, is one of the very few indicators we have to identify retinal disorders in premature infants. He closed by saying that this could lead to new hypotheses in ROP prevention, as well as new treatment strategies.

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11 September 2021 | Issue #2

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