ASRS 2018: Diabetic Retinopathy Session 1
Tomasz Stryjewski, Cindy Ung, Jay Wang First Year Vitreoretinal Surgery Fellows Massachusetts Eye and Ear Atlantic Coast Retina Club (ACRC) 2019 formally began on Friday January 11, 2019 at the beautiful Seaport Hotel World Trade Center Conference Center with case presentations from retina specialists from around the country. The afternoon prior was spent in the Massachusetts Eye and Ear Meltzer auditorium where trainees from the four Atlantic Coast Retina Club cities (Boston, New York, Philadelphia, and Baltimore) presented tough diagnostic challenges. As per tradition of the ACRC, cases were presented as mysteries and colleagues throughout the room would opine on a possible diagnosis, always with lively discussion and debate. Here are some highlights from the meeting. Dr. Susan Bressler of the Wilmer Eye Institute presented an unusual maculopathy in a patient who had been taking pentosan (brand name: Elmiron) for nearly two decades, a medication used for the treatment of interstitial cystitis. She reviewed the recent literature on this emerging disorder (Pearce et al. Ophthalmology 2018) and advised retina specialists to take a careful medication history, especially of medications taken chronically, who present with a pigmentary maculopathy. Dr. Caroline Baumal of Tufts presented a case of a hemorrhagic maculopathy in a young male in the ICU, who was found down and unresponsive following an assault. The maculopathy had a petalloid pattern, primarily affecting Henle’s layer. There were great discussions about the mechanism of the deep hemorrhage, focusing on new insights that suggest that the deep capillary plexus may only have venous flow. Finally, closing out the morning presentation of cases, Dr. Dean Eliott of Mass Eye and Ear presented a case of West Nile virus chorioretinitis. The case was notable in that at the time of presentation to the Retina Service, the patient was admitted with an “unknown” encephalitis. A spinal tap had been negative by PCR for a panel of arboviruses, including West Nile. Despite this, the retina exam findings were so classic for West Nile chorioretinitis. Laboratory studies were repeated, however this time, serum antibodies were ordered and the patient was found to have highly elevated IgM titers for West Nile. In the era of ever increasingly available diagnostic studies, this case served as a good reminder that we must not lose our clinical acumen and to maintain a high degree of suspicion, as every test has a false negative rate. Saturday was the Macula 2019 conference, transitioning from mystery case presentations to a day of lectures and panel discussions. The first session of the day centered on current and future approaches to AMD. We heard from Dr. Rahul Khurana who identified that a group of patients from the HARBOR trial who achieved peak vision early, actually ended up with the worst vision at the end of the study. Dr. Geoffrey Emerson then brought to our attention cases of intraocular inflammation following aflibercept injections that seemed to be associated with certain lots of syringes possibly related to silicone oil. Dr. Richard Spaide then shared with us a new type of meta-analysis on anti-VEGF injections for AMD in which he included not only randomized trials but all types of studies. He was able to show a dose-response curve and an optimal number of injections per year of 8-9 based on a cost-utility analysis, and argued that as a whole, retina specialists are undertreating wet AMD. Dr. Lawrence Yannuzzi then took us back in time and offered a wonderful review of PCV, or aneurysmal type 1 CNV. We then heard from Dr. David Zacks who gave us an overview of the molecular mechanisms of cell death and current and potential future targets for neuroprotection. Finally, Dr. Peter Kaiser gave a comprehensive overview of drugs being developed in various stages such as brolicizumab and conbercept and compared their properties with existing anti-VEGF agents. We then commenced with our second session of the day on vitreoretinal surgery. Dr. Phil Ferrone kicked off the session and gave a great clinical overview of strategies and approaches for pediatric retinal detachment. Dr. Richard Kaiser then reviewed current approaches to treat PVR with an emphasis on prolonged treatment throughout the entire disease course, focusing on promising data with isotretinoin and methotrexate. We then heard from Dr. John Thompson who went over classification of lamellar macular holes and pseudoholes, and their surgical outcomes. Dr. Fernando Arevalo then outlined the benefits of preoperative anti-VEGF for tractional retinal detachment in PDR even despite the risk of progression of TRD in some eyes. Dr. Allen Ho then gave a great talk about novel approaches to subretinal stem cell delivery using the suprachoroidal space. The afternoon session began with a lively panel discussion of the management of several cases including proliferative sickle cell retinopathy, CRVO, and PDR. The panelists were in agreement for the most part, but there remained continued debate over the initial choice of anti-VEGF versus PRP in patients with concomitant PDR and DME. Research presentations resumed with a session on tumors and uveitis. Dr. Carol Shields shared the use of multimodal imaging to predict the risk for transformation of choroidal nevi into choroidal melanoma. Dr. Brian Marr then gave us an update on preliminary results on new vision-preserving therapies for uveal melanoma, and for metastatic uveal melanoma. We then switched gears to uveitis and heard a very clinically relevant talk by Dr. Janet Davis about unusual presentations of various causes of infectious uveitis. Dr. Sunil Srivastava then gave an overview of local therapies for uveitis including steroid implants and non-steroidal local therapy. The session concluded with an informative review on new immune-modulating therapies for cancer and the diversity of adverse ocular side effects they can produce, given by Dr. James Dunn. We then continued with a session on new imaging with a talk from Dr. Neil Bressler about the rise of the application of deep learning to retina and ophthalmology and implications for future eye screening. Dr. David Sarraf then showed us the full spectrum of PAMM lesions ranging from a mild perivenular pattern to a full thickness infarction and important insight into retinal capillary flow. Dr. Bailey Freund then gave a very interesting talk about type 1 neovascularization and its potential protective effects against overlying atrophy of the retina. He showed several cases where allowing the type 1 NV to grow under the fovea seemed to prevent atrophy. Dr. SriniVas Sadda gave an overview of wide field imaging, current devices and new nomenclature. Dr. Cynthia Toth then showed us current and novel applications of intraoperative OCT, including considerations of how to best incorporate and visualize the additional information provided by OCT to improve surgical outcomes. The last session of the day focused broadly on new therapies. Dr. Peter Campochiaro started the session with a nice overview of the gene therapy pipeline and potential pitfalls. Dr. Al Maguire followed with a related talk about the more technical aspects of subretinal injection for gene therapy, and tips for success with the procedure. We were then treated to an overview of strategies for sustained anti-VEGF delivery with a focus on the port delivery system and results from the phase 2 trials. Dr. Thomas Albini then shared several cases of severe vision loss from TRD after intravitreal injections of “stem cells”. It turns out that these stem cell clinics can exist outside of FDA regulation because of a loophole in old federal legislation. Finally, Dr. James Handa ended the session and meeting with a great talk about current understanding of the pathophysiology of AMD and the need for a systems biology approach requiring integration and collaboration between a “dream team” of clinicians, scientists, and bioinformatics experts to come up with new insights. With that, a day of great talks concluded ACRC/Macula 2019 in Boston. It was once again a fantastic meeting with an ever growing attendance from retina specialists even outside the East Coast. We look forward to ACRC/Macula 2020, which will be hosted in New York City. Please mark your calendars: January 9 for trainee presentations, January 10 for the ACRC faculty case presentations, and January 11 for the Macula 2020 meeting.