Day 4 of the ASRS annual meeting has provided us with even more clinically relevant information regarding neovascular age-related macular degeneration (nvAMD) and retinal detachments (RDs). Both Geoffrey Emerson and Rahul Khurana addressed the possibility of inadvertent intraocular silicone oil injection during treatment of nvAMD with bevacizumab. Dr. Emerson performed an elegant experiment demonstrating that silicone oil globules can be expelled from BD insulin syringes while BD tuberculin, HSW insulin, and silicone free syringes appear not to carry the same risk. If you are using bevacizumab that is pre-loaded in BD insulin syringes and are unfortunate enough to have injected some silicone oil droplets into a patient, Dr. Khurana showed us that there is no need to take the patient for a vitrectomy right away. In his study, only 66% of patients with silicone oil droplets in the vitreous cavity were symptomatic, and approximately 90% of these patients experienced spontaneous resolution of their symptoms without any intervention (despite the silicone oil still being present in the eye).
All of us have taken care of patients with nvAMD who fail to respond to anti-VEGF injections given at 4 week intervals, and for these patients the options are generally limited to supplemental photodynamic therapy, steroids, or more frequent anti-VEGF dosing. We heard three presentations this morning about novel therapeutic agents that may be used to complement anti-VEGF therapy in these “treatment-resistant” patients. Raj Maturi provided preliminary data from subjects randomized to aflibercept monotherapy or aflibercept+sirolimus for the treatment of nvAMD. While there was no difference in final visual acuity (VA) between the groups, there was a trend towards a greater reduction in central subfield thickness in the group receiving combination therapy. Similarly, Christine Gonzales showed us that the tissue factor inhibitor ICON-1, when given in combination with ranibizumab, can reduce the number of retreatments compared to patients given ranibizumab alone. Most promisingly, Pravin Dugel presented data suggesting that treatment with ranibizumab and OPT-302, a VEGF-C and D inhibitor, can result in a gain of one line of VA in patients who were previously deemed to be treatment resistant.
Jaya Kumar and Russell Pokroy provided us with excellent information about subretinal hyper-reflective material (SHRM) in patients with nvAMD. Eyes with large areas of SHRM or SHRM with well-defined borders tended to have poor visual outcomes compared to eyes without these features, and this knowledge allows us to better counsel patients with nvAMD about their visual prognosis.
Shifting gears to the management of retinal detachment, Rajeev Muni presented the one-year results of the PIVOT study, a well-designed clinical trial comparing pneumatic retinopexy and vitrectomy for repair of a primary rhegmatogenous RD. The main findings were that the reattachment rate was higher with vitrectomy (~90%) than with pneumatic retinopexy (~80%). However, pneumatic failures did not jeopardize the final reattachment rate, and patients in the pneumatic retinopexy arm had superior VA outcomes at 1 year. Daniel Connors presented data on a common problem facing vitreoretinal surgeons, which is that of the non-diabetic vitreous hemorrhage. In a retrospective analysis of 52 eyes that were taken for either early (within 10 days of presentation) or later (after 10 days) vitrectomy, he showed that ultrasonography fails to detect as many as half of retinal tears that were later discovered during vitrectomy. Thus, early vitrectomy may be warranted in these patients to prevent progression to RD.
More highlights from Day 4 of the ASRS meeting include panel discussions on clinical trial results and their application to clinical practice, challenging surgical cases, and workshops on IOL fixation for the vitreoretinal surgeon and future therapies for blinding retinal diseases. Day 5 promises to be filled with even more cutting-edge information that can be used to guide our clinical practice, so check back in for more updates and information tomorrow!
Max Stem, M.D.
Vitreoretinal Surgery Fellow
Associated Retinal Consultants/William Beaumont Hospital