AAO 2017 Retina Subspecialty Day: Macular Session

Doran Spencer, MD, PhD
Vitreoretinal Surgery Fellow
Univ. of California, San Diego

In the Macular session, Dr. Glen Jaffe of Duke started off by discussing the current state of affairs with regards to “Intraocular sustained drug delivery.” This included the well-established steroid-eluting Retisert and Ozurdex, as well as more novel approaches such as genetically engineered cells that express biologically active proteins (CNTF) and refillable implants. The conditions targeted by these devices  include AMD, DME and uveitis. The LADDER study, now in Phase 2, targeting neovascular AMD, involves a refillable trans-pars plana port. Dr. Jaffe finished by discussing a project that he is overseeing  that implicates an injectable fluocinolone implant, as well as a separate suprachoroidal delivery system of triamcinolone for uveitis and CME.

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Dr. Giuseppe Querques of Milan, Italy gave an overview of  central serous chorioretinopathy (CSR), including the epidemiology, clinical characteristics, evaluation with different imaging multimodalities (multicolor, OCTa, FAF and ICGa), and treatment options. Specifically, the use of eplerenone followed by half-fluence PDT was presented.

Dr. Francine Behar-Cohen of Lausanne, Switzerland presented the latest on CSR management, including her experience with appropriate observation (3 months) versus the need for intervention when it does not spontaneously resolve (52% by 3 months, 84% by 6 months). Unfavorable characteristics were mentioned, including age > 40 years, large size, choroidal thickening on OCT and circadian dysfunction (i.e., shift work). The role of mineralocorticoid receptor (MR)/glucocorticoid receptor (GR) imbalance was discussed, as well as management with MR antagonism and GR agonism.

Dr. Szilard Kiss of Weill Cornell provided an overview of gene therapy for wet AMD, including three phase I trials. The overarching goal is the expression of durable anti-VEGF molecules within the eye, and adeno-associated virus (AAV) has been a popular vector although evidence suggests that neutralizing antibodies are problematic. This has been overcome in part through the engineering of novel AAV capsids, and effective delivery of molecules similar to ranibizumab and aflibercept has been achieved, with duration up to two years.

Treatment options for vitreomacular traction were discussed by Dr. Robert Avery of California Retina. This includes observation, which results in 31% spontaneous resolution, and definitive treatment with PPV. Ocriplasmin has shown 48% success in well-selected cases, whereas pneumatic vitreolysis boasts an 85% success rate in a recent meta-analysis.

Screening guidelines for hydroxychloroquine retinopathy were presented by Dr. David Browning of Charlotte, North Carolina. Specifically, he advocated for the use of 5.0 mg/kg on ideal body weight, not real body weight, as otherwise this can result in toxicity for “short, obese” patients. This was based on his experience with 567 patients, 41 of whom experienced toxicity.

Clinical trials for retinal degenerations were the topic of a presentation by Dr. Byron Lam of Bascom Palmer. These specifically included gene therapy via subretinal delivery of AAV vectors for RPE65-associated disease (phase 3), choroideremia (phase 2), achromatopsia (phase 1-2), and X-linked RP (phase 1). X-linked retinoschisis (phase 1, AAV), Stargardt maculopathy (lentiviral, phase 1-2) and Usher syndrome are also underway (phase 1-2). Studies of retinal prostheses include Argus 2 and Alpha IMS.

Dr. Dean Eliott of MEEI presented an update on hemorrhagic occlusive retinal vasculitis, the devastating condition first described in 2014 and since recognized to be associated with intraocular administration of vancomycin. Several mild cases have been described since then, and its routine use during cataract surgery was strongly discouraged.