ASRS 2023: Surgical Session I

Haley S. D’Souza, M.D.
Mayo Clinic
Rochester, MN

The Surgery Symposium 1 of the ASRS 2023 Annual Meeting was moderated by Drs. Kevin Blinder and Dharmesh Kar, and highlighted studies aimed at improving outcomes in vitreoretinal surgery.

The first speaker was Dr. Matias Iglicki from Hospital de Clinicas Buenos Aires, who presented “Naïve Subretinal Hemorrhage in Neovascular AMD—Pneumatic Displacement, Subretinal Air, and tPA: Subretinal vs. Intravitreal Aflibercept: The NATIVE Study.” The NATIVE Study compared the safety and efficacy of sub-retinal vs. intravitreal aflibercept administered during pars plana vitrectomy (PPV) for naïve subretinal hemorrhage secondary to macular degeneration. Both groups achieved similar anatomic and visual outcomes. Patients who received subretinal aflibercept required a statistically significant lower need for anti-VEGF injections in the 24 months following PPV, indicating possibly more efficacious treatment of choroidal neovascularization with subretinal anti-VEGF delivery.

Dr. Alan Franklin of Diagnostic & Medical Clinic then presented “Intraoperative Fluorescein Angiography to Efficiently Identify Many Biomarkers and Guide Surgical Decision-Making.” During this talk, Dr. Franklin described a technique he developed to enable real-time intraoperative fluorescein angiography during PPV. He demonstrated its use in identifying clinical biomarkers such as neovascularization, capillary dropout, and vascular occlusions, enabling a targeted intraoperative treatment approach. This technique may enable both identification and treatment of subtle pathology and sparing of healthy tissue from potential overtreatment.

Dr. Ahmed Sallam from University of Arkansas for Medical Sciences presented “Type of Vitreoretinal Anesthesia and Sources of Variation in the United States.” This study examined national practice patterns in the United States regarding Monitored Anesthesia Care (MAC) use for vitreoretinal surgery. Most cases were performed under MAC, with the remainder being predominantly performed under general anesthesia. Most variation in MAC use was attributable to patient characteristics, with older age and ASA Grade 4 or 5 physical status (higher medical comorbidities) being independently associated with likelihood of having surgery under MAC. Complex cases such as tractional retinal detachment and cases of scleral buckling without vitrectomy were more likely to be performed under general anesthesia.

Dr. Shawn Kavoussi from Texas Retina Center presented “27-Gauge vs 25-Gauge Vitrectomy for Symptomatic Vitreous Opacities: Outcomes Using Infrared Video.” This study utilized infrared fundus video to generate a standardized Macular Vitreous Opacity Score (MVOS), which was used to quantify pre-macular vitreous opacities before and after PPV for symptomatic vitreous floaters. Using the MVOS, this study demonstrated that both 25-gauge and 27-gauge PPV significantly lowered the quantity of vitreous floaters, and patients in both groups experienced significant improvement in symptoms. Lower case times and cut times were noted in the 27-gauge group compared to the 25-gauge group.

Dr. Kapil Mishra from Wilmer Eye Institute presented “Determining Vitreoretinal Surgery Fellow Surgical Competency: Survey of Fellowship Program Directors.” The survey was distributed to both program directors and fellows in vitreoretinal surgery training programs at both private and academic institutions. Program directors agreed that graduating fellows should be comfortable with most types of advanced vitreoretinal surgeries. There was a lack of consensus regarding a specific minimum number of surgeries required to attain competency, a minority of respondents indicated that there is no absolute minimum number. The most commonly utilized strategies in evaluating fellow surgical competency were direct surgical observation, discussion with other faculty, and outcomes of fellow cases. This study highlights the opportunity for creating a standardized method of assessing vitreoretinal fellow surgical competency.

Dr. Brittany Powell of Fort Belvoir Community Hospital presented “Mastering the Retrobulbar Block: Using a New 3D-Printed Simulator for Practical Training.” Most participants indicated that they had performed retrobulbar blocks in residency, but some had never performed a retrobulbar block prior to utilizing the training model. The 3D printed model includes a face with eyelids that can be manipulated during the procedure and an eye with an attached extraocular muscle cone and optic nerve. About half of participants, particularly those with more clinical experience, felt that the model offered good anatomic fidelity. The study surveyed participants before and after they utilized the training model, and showed a significant increase in participant comfort with performing a retrobulbar block after utilizing the training model.

Dr. Ayman Elnahry from Bascom Palmer Eye Institute presented “Intravitreal Infliximab for the Treatment of Proliferative Vitreoretinopathy Associated with Rhegmatogenous Retinal Detachment: The Phase II FIXER Trial.” This is the first human study to evaluate a TNF-α inhibitor in the treatment of reduces proliferative vitreoretinopathy (PVR). This trial follows evidence that intravitreal infliximab (IVI) decreases PVR formation in animal models with dispase-induced PVR. Adult patients with grade C PVR were randomized 1:1 to receive either silicone oil alone or silicone oil with IVI at the end of PPV for retinal detachment with PVR. Three vitreoretinal surgeons performed all the surgeries in the trial. The primary outcome measure was safety and efficacy in achieving complete retinal attachment without tamponade at 6 months. Secondary outcome measures included best corrected visual acuity (BCVA) and single-operation success rate (SOSR). All eyes in the IVI group achieved anatomic success without tamponade at six months, compared to all eyes but one achieving anatomic success in the control group. The SOSR was higher but not to a statistically significant level in the IVI group. Final BCVA was slightly better in the IVI group (statistically significant), which could be due to the higher SOSR seen in the IVI group. Future investigations to assess alternative doses, treatment regimens, and efficacy of other TNF-α inhibiting agents were suggested.

Finally, Dr. Pedro Tetelbom from University of Arkansas for Medical Sciences presented “Comparison of Complete vs. Incomplete Closure of Zone 3 Scleral Lacerations.” Zone 3 scleral lacerations are technically challenging to repair due to their posterior location on the globe. This retrospective study demonstrated that eyes with incomplete repair of zone 3 lacerations had the similar outcomes to lacerations that underwent complete repair in terms of total number of surgeries, final intraocular pressure, BCVA, silicone oil use, choroidal detachment, and retinal detachment. This similarity in outcomes was attributed to the aggressive manipulation of the globe required to achieve complete closure. A small number of eyes in the complete closure group were enucleated, whereas no eyes from the incomplete closure group were enucleated.