ASRS 2023: Retinal Detachment Symposium

Samuel Feldman, MD
University of California Davis Eye Center
Sacramento, CA

Monday morning’s talks started off with the Retinal Detachment Symposium, which was moderated by Philip J. Ferrone, MD and Alay S. Banker, MD.

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Emily Shepherd, MD was the first on stage and spoke about the risk of developing proliferative vitreoretinopathy (PVR) in a patient’s second eye after rhegmatogenous retinal detachment (RRD) with a history of PVR development in a patient’s first eye. Using the Vestrum database, Dr. Shepherd and colleagues were able to analyze outcomes from over 50,000 RRDs. Their analysis showed that having PVR after the first eye RRD puts a patient at over a 3-fold higher risk of developing PVR after the second eye RRD repair.

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Yoshihiro Yonekawa, MD then discussed the benefits of extended internal limiting membrane (ILM) peeling for Grade C PVR. This large international collaborative study compared outcomes of no ILM peeling, ILM peeling within the arcades, and extended ILM peeling past the arcades. Their results showed that ILM peeling resulted in better anatomic outcomes (significantly higher single surgery success) and better visual outcomes. Additionally, they found that extended ILM peeling was superior to limited ILM peeling.

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Christina J. Flaxel, MD then presented data from the Phase 3 GUARD Trial. This trial investigated intravitreal methotrexate to prevent PVR. Eyes with a history of recurrent RRD due to PVR or open globe injury with RRD were included in this study. The initial study design included an intervention group, which would receive routine surgical care with 13 injections of methotrexate over 4 months, and a control group where only routine surgical care was performed. The control group was ultimately eliminated from this study given a few investigators expressing hesitancy to withhold methotrexate. A historical controls group was created from prior clinical trials, which Dr. Flaxel noted were well matched to the intervention group.

Patients who received intravitreal methotrexate in the intervention group of the GUARD Trial were significantly less likely to develop a recurrent RRD within 6 months and less likely to develop complications such as epiretinal membrane formation. The only adverse event noted was a mild-moderate punctate keratitis in a small subset of patients.

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Richard B. Rosen, MD then joined the stage to present a creative new way to treat retinal breaks with endolaser during a chandelier-assisted scleral buckle. A sleeve for the endolaser was created from an 18g Angiocath. This allows the use of endolaser without the risk of dragging vitreous. He presented a series of cases that demonstrated the safety of this technique.

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After a brief discussion, Bryon R. McKay, MD, presented on the natural course of outer retinal restoration after fovea-off RRD. It was found that disruption of the outer retina was associated with worse visual acuity, but outer retinal microstructure can continue to improve out to 2 years post-operatively.

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Isabela Martins Melo, MD then presented on the role of bacillary layer detachments in the formation of macular holes in fovea-off RRDs. It was found that 20% of RRDs present with some level of bacillary layer detachment. Additionally, she noted that bacillary layer detachments with lamellar holes are highly likely to become FTMHs.

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K. V. Chalam, MD, PhD presented on the use of intravitreal triamcinolone acetonide and moxifloxacin intraoperatively to prevent the need for post-operative drops. He found that there was no difference in post-operative inflammation, IOP, or infection rate.

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Finally, Carl Shen presented on intraretinal silicone oil migration. He characterized a novel phenotype of intraretinal silicone oil on OCT. It is characterized by small hyporeflective spheres within the inner retina and hyperreflective tails in the outer retina. He cautioned against ILM peeling in retina detachment with silicone oil tamponade unless necessary as this increased the likelihood of intraretinal silicone oil.

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