VBS 2022 – Debates

Nita Valikodath MD, MS
Vitreoretinal Surgery Fellow
Duke University Eye Center

“The time you enjoy wasting is not time wasted” was the title of Session 3: the Debates section of VBS. The hotly debated topics were the utility of intraoperative OCT (iOCT), optimal treatment modalities for neovascular AMD (NVAMD), and laser vs. anti-VEGF for retinopathy of prematurity (ROP).

Debate 1: Intraoperative OCT

The first debate was kicked off by Dr. Dilraj Grewal, MD (Duke University) who argued iOCT is necessary for the future of retina surgery. He said “it takes the guesswork out of surgery.” iOCT allows for better visualization of tissues and feedback on depth, allowing surgeons to see exactly where their instruments are. He described how iOCT can be integrated in real time with the use of artificial intelligence. Dr. Katherine Talcott, MD (Cleveland Clinic) debated the position that iOCT is useless. A key point she made was that it does not change what we do in the OR for bread-and-butter retina cases. She tested this by using iOCT one day in all of her surgical cases, which included a chronic retinal detachment, traumatic dislocated intraocular lens, non-clearing vitreous hemorrhage, ERM, and macular hole. She emphasized that iOCT did not alter the surgical plan or outcome for any case. She also discussed how iOCT can be prohibitive due to cost, time, and lack of reimbursement. This excellent debate stirred up a great discussion from the audience, specifically that the current systems are not well-integrated into our visualization and operating systems, and as this evolves it may become easier to use.

Audience vote: The winner is…Dr. Katherine Talcott!

Debate 2: Wet AMD

In this debate, Dr. Ashley Crane, MD (Retina Vitreous Associates of Florida) argued for the advantages of the port delivery system (PDS) versus standard of care for wet AMD. She stressed the excellent efficacy of PDS with prolonged drug delivery with reduced need for intravitreal injections. She emphasized that the overwhelming majority of surveyed patients preferred PDS over intravitreal injections. However, she also mentioned the higher risk of endophthalmitis with PDS and need for careful attention to the surgical procedure to decrease the risk of complications.

Dr. Robert Avery, MD (California Retina Consultants) argued for gene therapy as the next frontier in the treatment of NVAMD as a one and done procedure. Dr. Avery highlighted the difficulty in asking patients to come in monthly for injections, presenting one of his own patients who has received over 150 intravitreal injections. Dr. Avery showed how subretinal gene therapy may obviate the need for any intravitreal injections in some patients. Additionally, the subretinal therapies have been overall well-tolerated by patients in wet AMD clinical trials, while there were some concerning signals in intravitreal gene therapies in a recent DME trial.

Dr. Esther Lee Kim, MD (Orange County Retina) defended the tried-and-true treatment for wet AMD: continued intravitreal anti-VEGF injections. She showed that millions of intravitreal injections have been performed and emphasized the low risk of adverse effects such as endophthalmitis or retinal detachment. Dr. Kim wittily defended repeated injections and showed us that “not all innovation is better.” She highlighted the higher risk of endophthalmitis with PDS and the potential risk of anti-VEGF over-expression with gene therapy.

Audience vote: The winner is…Dr. Esther Lee Kim!

Debate 3 – ROP

The session ended with a debate on laser vs anti-VEGF for ROP. Dr. Safa Rahmani, MD MS (Northwestern University) argued for the benefits of laser which include its effectiveness, streamlined care of patients who are often lost to followup, and less surprise recurrence of vascular activity. While laser might have a learning curve, she explained that it was most often a “one and done procedure.” She emphasized laser as a successful treatment option for decades in babies with ROP. Conversely, with anti-VEGF, there is a risk that ROP can potentially reactivate, even years later. She also points out the unknown systemic side effects and consequences that may occur with intravitreal anti-VEGF injections.

Dr. Eric Nudleman, MD PhD (Shiley Eye Institute, UCSD) argued for anti-VEGF therapy for ROP. He emphasized the benefits of anti-VEGF injections particularly the ease with which they can be performed as a bedside procedure without risks of general anesthesia. Additionally, he highlighted the rapid response in ROP patients to anti-VEGF treatment and resulting larger visual field and decreased risk of induced myopia compared to laser treatment. He showed how the ROP vascular severity score was worse in patients that received laser compared to anti-VEGF. After the debate, the panel discussed long-term follow up of these patients and all agreed that when there is any risk to loss to follow-up, laser is the preferred treatment option. The panelists also emphasized that sometimes monotherapy with laser or anti-VEGF isn’t the answer, but a combination of treatments is required.

Audience vote: The winner is…Dr. Eric Nudleman!