Retina Prophecies for 2019
Jose J. Echegaray, MD Vitreoretinal Surgery Fellow Bascom Palmer Eye Institute Nathan Scott, MD MPP Ophthalmology Resident Bascom Palmer Eye Institute The High Risk Non-Exudative AMD session kickstarted with an interesting talk by Dr. Giuseppe Querques on the spectrum of treatment-naive subclinical macular neovascularization, also termed non-exudative choroidal neovascularization (NE-CNV). In this longitudinal study of 32 eyes with 20-month follow up, those who showed exudation before 6 months of follow up had a higher rate of growth and perfusion density at baseline than those who had exudation after 6 months of follow up or remained quiescent throughout the study. The authors proposed that these differences in baseline OCT-A findings may suggest different pathologic pathways in those CNVs which activate at earlier time points. Dr. Philip J. Rosenfeld followed with a very interesting talk illustrating how SS-OCTA using the optical microangiopathy algorithm developed by Dr. Ruikang Wang may detect neovascularization in non-exudative AMD long before exudation occurs. Specifically, macular neovascularization was detected using the outer retina-to-choriocapillaris (ORCC) slab with a 14-fold increase in risk of exudation in eyes with subclinical lesions at 2 years. He emphasized that although subclinical lesions may be detected earlier using OCT-A, treatment is not recommended until symptomatic exudation develops. The session continued with a terrific presentation by Dr. Jeffrey Heier, who presented the 12-month data of the ProCon study. In this interim analysis at 12 months, there was no benefit of quarterly intravitreal aflibercept injections as a prophylactic treatment against conversion to neovascular AMD in high risk dry AMD eyes when compared to quarterly sham injections. The overall rate of conversion in high risk dry AMD was 7.9%, which is comparable to other major trials such as the CATT study. Dr. Lawrence Singerman then presented data from the CLEAR study, a 2-month, multicenter, observational study testing the Checkup Vision Assessment System, a mobile-based application that performs at-home visual acuity and Amsler grid testing in patients with AMD and diabetic retinopathy (DR). The authors suggest that the Checkup mobile app is a user-friendly and reliable method to monitor patients with AMD and DR in clinical and home settings. The theme of at-home monitoring devices continued with an interesting presentation by Dr. Anat Loewenstein featuring the Notal-OCT system, designed for at-home self-operation by elderly individuals. Following a 2-minute tutorial, 94% of elderly patients were able to use the system and capture adequate images, which were analyzed by the Notal OCT Analyzer. This validated AI algorithm is able to detect intraretinal fluid, subretinal fluid, and pigment epithelium detachments. Dr. Loewenstein emphasized that access to this system has the potential to enhance our management decisions in AMD. Dr. Daniel F. Martin closed the session with an overview of theoretical and practical challenges in clinical trial design for the prevention of exudative AMD in high risk dry AMD eyes. He began reviewing lessons learned from recent Investigator Sponsored Studies (PREVENT and ProCon), suggesting that risk reduction with anti-VEGF treatment at 3-month intervals appear to be disappointing, while 2-month treatment intervals would theoretically increase the concern for treatment burden and patient compliance in the real world. Dr. Martin’s take-home message was that using current anti-VEGF regimens to prevent exudative CNV would require high treatment burden and cost to achieve significant risk reduction and that designing a large RCT with current treatment and surveillance patterns to prevent exudative CNV is not viable at present.