Shaheer Aboobaker, MD
Second Year Vitreoretinal Surgery Fellow
St. Michael’s Hospital, University of Toronto
Carolina Francisconis, MD
Second Year Vitreoretinal Surgery Fellow
St. Michael’s Hospital, University of Toronto
Rachel Trussart, MD, FRCSC
Second Year Vitreoretinal Surgery Fellow
University Health Network and Sunnybrook Health Sciences Centre, University of Toronto
Welcome back to coverage of the 2018 Fellows Forum in Chicago. Saturday January 27th was the second day of the meeting, where we had exciting panel discussions and debates, followed by the legendary Fellows Forum bowling tournament. The extensive day is divided into two separate posts.
Retinal Detachment Panel
Dr. Michael Jumper ran a retinal detachment panel discussion to start the busy day off. He presented a variety of retinal detachment cases commonly encountered in daily practice for opinion and discussion. Some of the discussion included tips for drainage of subretinal fluid in external repairs; using a chandelier during external subretinal drainage under direct visualization.
Dr. David Chow mentioned his experience with this under the Ngenuity viewing system as “spectacular”; Dr Peter Kaiser shared his experience of not draining any subretinal fluid during an external repair but injecting a gas bubble at the end of the case to tamponade the break in addition to a buckle; differences in pathology and management of GRT’s versus dialyses; management of chronic mac on RD’s (including the role of observation in these cases); and tips on dealing with PVR and multiple breaks.
Dr Michael Jumper shared his technique of using a bimanual approach with a lighted pick to deal with difficult PVR membranes. He also recommended using preoperative periocular steroid in an attempt to increase the intraocular pressure prior to surgery in cases of hypotony. Dr David Chow reminded us of using 6mm trocars in cases of pars plana detachment and choroidals to avoid trocar placement in the subretinal space.
Vitreoretinal Surgery Debates
Debate #3: Recurrent MHS – ILM Flap or Otherwise Needed
PRO Tamer H. Mahmoud
Sadly, Dr. Audina Berrocal was unable to attend this debate and Dr. Tamer Mahmoud won by default but he did share some of his experience with recurrent macula hole repair using retinal transplants and reports that despite a minimal improvement in distance vision in some cases, patients reported resolution of their central scotoma and improved near vision.
Debate #4: We Need Ultrasonic Cutting
PRO Carl C. Awh
CON David R. Chow
Dr. Carl Awh faced up against Dr. David Chow in this clash between two great friends. Dr. Awh argued this was the next step forward in cutter technology and showed a beautiful video showing minimal vitreous traction during cutting. He also reported on the higher cut rates and showed the ability of the cutter to do other tasks such as inducing a PVD and the ability of the cutter to extract silicone oil in an efficient manner, which would be a great improvement on current technology. He did mention, however, that this cutter would still need to be tested on diabetic membranes.
Dr. David Chow, albeit a great fan of new technology, argued that this was an unproven technology and that the current technology is efficient, safe and gets the job done. He presented basic science suggesting safety concerns with ultrasound energy and retinal damage and contended that while this technology may have a place in the future, that given the current safety concerns, is not yet ready for prime time.
Debate #5: We Need Intraoperative OCT
PRO Dean Eliott
CON Michael Jumper
Dr. Dean Eliott argued for the use of intraoperative OCT, specifically in cases of ERM peels, lamellar macula holes, chorioretinal biopsies and assessment of approximation of Argus II implants to the retina and to exclude iatrogenic macula holes. He reminded us of the feasibility of integration of this with future technology (i.e. heads up display and microscope viewing systems)
Dr. Michael Jumper countered that this technology is expensive and did not alter his surgical management and that issues such as resolution and image shadowing prevented uptake in everyday clinical practice.
Macular Surgery Panel
Dr. David Chow ran a macula surgery panel and emphasised the importance of hyaloid identification and removal in every case. He encouraged the use of stains during early training and presented his techniques for hyaloid detachment, including port down approach with the cutter and aspirating adjacent to, not above, the optic nerve with slow and steady force lifting the hyaloid directly upwards to reduce peripheral tears.
He reminded us of the use of longer forceps for myopic eyes or simply removing the trocars to gain a few extra millimetres in long eyes to safely reach the ILM. Dr. Tarek Hassan suggested his technique for dealing with recurrent macula holes in which he manipulates the edge of the hole to remove any residual ILM preventing closure of the hole.
Dr. Chow mentioned his use of a membrane scraper to smooth out retinal folds, while Dr. Awh questioned the need for this as, in his experience, these folds tend to settle with time.
Diabetic Retinopathy Debates
Debate #6: Role of antiVEGF Therapy in the Management of DR
PRO Peter K. Kaiser
CON Dean Eliott
Dr. Dean Eliott critically assessed Protocol S and suggested that insufficient laser may have been performed on the patients in the PRP arm and his concern that PASCAL laser may be less effective than single shot laser and that PRP would be an efficient once off treatment, especially in potentially non compliant patients. He defended the visual field concerns by showing that peripheral VF loss was not noticed on quality of life evaluation.
Dr. Peter Kaiser countered by arguing that anti-VEGF in PDR was truly a disease modifying treatment and presented data showing that patients had less visual field loss and better visual acuity.
Debate #8: Role of Subthreshold Laser for DME
PRO David R. Chow
CON Tamer H. Mahmoud
Dr. Tamer Mahmoud argued that insufficient evidence currently exists for the effectiveness of micropulse laser for DME.
Dr. David Chow countered by showing published evidence of safety and efficacy of micropulse laser as primary treatment and as adjunctive therapy to reduce the anti-VEGF burden in the treatment of DME, citing Capello et al (IOVS 2017) and Moisselev et al (EJO, 2017, Epub ahead of print). He also mentioned its usefulness in treating chronic CSR. He argued that given its safety, we had nothing to lose as we would be doing no harm. He suggested patience in assessing treatment response as it is usually slower than anti-VEGF (1-4 months) but more durable; he noticed a tendency of undertreating and highlighted the importance of high density treatment.
Diabetic Retinopathy Panel
Dr. Tarek Hassan ran a panel on diabetic retinopathy and presented clinical cases for discussion. Of note was the importance of symptomatology. Most on the panel agreed that it is difficult to justify treatment to your patient in the absence of symptoms with good vision and mild DME. Dr. Tahmer Mahmoud uses these occasions as an opportunity to educate and emphasize risk factor control. The role of focal laser was discussed in the setting of non central DME – the panel were in agreement of using focal treatment instead of grid laser. The panel was split on the topic of switching anti-VEGF agents versus adding or substituting for a steroid in cases of refractory DME.
Please stay tuned for Part II, where we bring to you the distinguished speaker, real world pearls, bowling action, and award recipients.
