Avni P. Finn, MD, MBA
Northern California Retina Vitreous Associates
Mountain View, CA
The Vit-Buckle Society 2021 Meeting: The Force Awakens, Episode 1 took place on April 14th. This was a fast-paced hybrid virtual meeting with the addition of live watch parties in New York City and Miami that joined in for discussion during the meeting. The watch parties added an extra element of liveliness to the discussion during a time where we are inundated by conventional virtual meetings.
IOL Acrobatics Debates: Maria Berrocal MD, Joseph Coney MD, Ninel Gregori MD, and Katherine Talcott MD
The program began with a debate around secondary IOL techniques. Dr. Maria Berrocal presented her pearls for cannula-based scleral haptic fixation technique and emphasized the relatively low risk of pupil distortion and corneal decompensation with this technique compared to others. Dr. Joseph Coney then demonstrated Gore-tex sutured lenses highlighting the durability of Gore-tex compared to polypropylene suture, which carries a well-documented risk of late-onset disintegration leading to IOL dislocation. He recommended fixating the IOL 3 mm posterior to the limbus to reduce the risk of iris chafing and burying the suture knots in the sclerotomies to reduce the risk of postoperative suture erosion.
Next, Dr. Ninel Gregori, presented her iris sutured secondary IOL technique, emphasizing its benefits in eyes with thin sclera or conjunctival scarring where scleral fixation is a less viable option. She uses McCannel sutures with 3-1-1-1 knots to reduce the risk of IOL dislocation, and passes the sutures as far away from the pupillary border as possible to reduce the risk of pupillary distortion.
Lastly Dr. Katherine Talcott, ended with a true and trusted technique: anterior chamber IOLs, referring to the long and favorable track record of this technique in terms of safety, durability, and visual outcomes. She recommends inserting the ACIOL via a scleral tunnel, constricting the pupil with a cholinergic agent, and using a Sheets glide to make insertion easier and safer.
A poll showed the majority of the audience preferred the sutureless scleral fixation technique for their secondary IOL cases.
Surgical Approaches in Medical Retina: Lejla Vajzovic MD
Dr. Vajzovic led us through two emerging therapeutic options for treating neovascular age-related macular degeneration (nvAMD): the Port Delivery System (PDS) implant by Genentech and RGX-314, a gene-therapy medication designed for one-time subretinal delivery, by REGENXBIO.
Genentech has completed Phase 3 trials for PDS in nvAMD and Dr. Vajzovic showed a video demonstrating the surgery to implant the PDS and discussed some of the technical challenges. While the device is promising, it requires a surgical technique not currently performed by most vitreoretinal surgeons.
RGX-314 is currently undergoing phase II trials for both nvAMD and diabetic retinopathy. This gene therapy was initially evaluated using a subretinal approach and is now being delivered using suprachoroidal injections. Dr. Vajzovic and the panelists highlighted the excitement surrounding reducing injection burden with these novel devices and therapeutics, but balanced this hope with the risks of surgical management and training needed for these new options.
Lightning Rounds: Matthew Cunningham MD, Kristen Harris-Nwanyanwu MD, Marianeli Rodriguez MD
Lightning Rounds was a great section at the meeting featuring quick fire case presentations and highlighting pearls in difficult surgical cases. Dr. Cunningham presented a recurrent diabetic tractional retinal detachment occurring under silicone oil. He showed the advantage of highlighting membranes using indocyanine green (ICG) dye when peeling and cautioned knowing when to stop peeling is important as persistent peeling of clinically insignificant membranes may lead to iatrogenic retinal breaks later in the case.
Dr. Harris-Nwanyanwu then presented a complex recurrent retinal detachment in the setting of proliferative vitreoretinopathy (PVR). The case highlighted the importance of complete hyaloid and vitreous removal at the time of the initial surgery as this serves as a scaffold for PVR membranes leading to recurrent detachments. Dr. Harris-Nwanyanwu’s case showed the advantage of employing triamcinolone to visualize the hyaloid in the initial case and in PVR cases to effectively peel and relieve all membranes exerting traction.
Dr. Marianeli Rodriguez showed bilateral irregular tractional full-thickness macular holes secondary to proliferative diabetic retinopathy. She demonstrated successful closure of the macular hole, emphasizing the importance of assuring complete hyaloid removal and the benefit of a wide ILM peel in these cases of tractional holes.
Handling Trauma as a Retinal Surgeon: Yewlin Chee MD
Dr. Yewlin Chee shared her pearls for performing retinal detachment repair in cases of posterior segment trauma. She recommends placing an encircling scleral buckle in most trauma cases at the time of PPV, due to the high risk of PVR, though acknowledged if muscles have been previously taken down for the globe repair this can be challenging.
She presented a challenging case of retinal detachment associated with sclopetaria demonstrating the fibrotic membranes that can become enmeshed within the retina making complete removal of membranes challenging. Dr. Chee and the panelists also discussed the currently ongoing GUARD trial evaluating the use of methotrexate in the prevention of PVR.
At the end of the meeting, Dr. Chee received the most votes for the best surgical presentation. Congratulations!
Diversity, Equity and Inclusion in Retina Panel: Reginald Sanders MD, Dr. Jessica Randolph MD, Basil Williams MD
This panel led by Basil Williams discussed the underrepresentation of minorities in the field of retina and the challenges to increase diversity within the field. This session was a highlight of the meeting. Dr. Randolph shared that underrepresented minorities account for only 12% of all physicians and less than 7% of ophthalmologists. All of the panelists pointed out the lack of data, which is at the crux of understanding the barriers minority trainees and physicians face and how to increase representation in the field. Drs. Sanders, Randolph, and Williams underscored the importance of understanding which career stages and practice settings suffer the most from underrepresentation, and that increased mentorship through professional societies is one way to address the problem.
Uveitis Surgery Pearls: Lisa Faia MD
In the final session of meeting, Dr. Lisa Faia presented her pearls for successfully performing surgery in patients with uveitis. Dr. Faia underscored the importance of controlling inflammation with at least 3 months of quiescent disease prior to intraocular surgery, meticulous surgery, and the early detection of post-operative complications. She explained the importance of escalation of immunosuppression to control the disease perioperatively and with her surgical videos demonstrated thorough and extensive membrane peeling and the utility of Healon in opening up funnel detachments in these eyes.
That wraps it up for the first episode of Vit Buckle Society’s annual meeting. The second episode will be taking place on May 20th at 8:30PM EST. Those interested can register at the meeting website: https://avenue.live/vbs/. This is the last episode for Vit Buckle Society this year, and the live viewing parties will be in Houston and Los Angeles.