March 3, 2017 Conference
Innovations and Controversies in the Diagnosis and Mangement of Uveitis
Professional Practice Gaps: The diagnosis and management of Uveitis can be challenging.
Program Objectives: Update on diagnostic innovations and therapeutic controversies to enhance management of the uveitis patient.
David Hinkle, MD
Michael E. Zegans
George N. Papaliodis
C. Stephen Foster
Oculopastics Subspecialty: Eyelid and Orbital Cancers
EDUCATION GAPS: Based on evaluations of prior oculoplastic and oncology talks, participants desired more information on outcomes with more recent advances in evaluating eyelid and orbit carcinomas as well management with new radiation protocols, new chemotherapies, and surgical techniques such as sentinel lymph node biopsy and extent of orbital surgery.
- To impart knowledge on new imaging protocols for evaluation of orbital/ head and neck tumors.
- To review newest techniques and indications for sentinel lymph node biopsy.
- To evaluate current statistics for efficacy of irradiation for orbital tumors.
- Update on new chemotherapies for eyelid carcinomas and melanomas.
Susan M. Tucker
Kevin Emerick, MD
Howard Hsu, MD
Michael E. Migliori
Gary Rogers, MD
Gary Rogers, MD
Professional Practice Gaps: We obtained feedback from ENOS members, reiewed evaluations from prior NEOS retina meetings, and discused with the Program Committe in order to identify current profession practce gpas for the NEOS membership. The knowledge and understanding of how to ttranslate guidelines from recent landmark clinical trials into clinical practive inthe areas of neovascular age-related macular degeneration, dry age-related macular degeneration, retinal vein occlusion, diabetic macular edema and diabtic retinopathy are lacking and will be addressed in this session.
1) Understand evidence-based guidelines for treatment of neovascular age-related macular degeneration, including optimal dosing regimens
2) Review clinical trial data for optimizing outcomes in patients with dry age-related macular degeneration
3) Evaluate data from studies addressing treatment of retinal vein occlusin and how these can be used to best guide clinical practice
4) Discuss current best practices for treatment of diabetic eye disease, including diabetic macular edema and proliferative diabetic retinopathy as well as future promising approaches.
Jennifer K. Sun
Anti-VEGF therapy changed the paradigm and expectations for neovascular AMD treatment. In managing patients with neovascular AMD, clinicians need to choose diagnostic imaging and testing, initial therapeutic agent, and treatment regimen; and in follow-up, whether and when to switch drugs. Available data from AMD clinical trials do not support a best practice in drug choice or treatment protocol, and drug selection may be affected by coverage benefit, concerns about compounding pharmacies and provider past experience. The rationale for switching agents is even less well developed. There is currently no best practice standard, although meta-analyses suggest that clinicians “under-treat” in the first few years. Longer-term findings demonstrate progressive vision loss and GA, most likely due to unveiling of the degenerative process when neovascular disease is controlled. Future directions for treatment of neovascular AMD should include neuroprotection as adjuvant therapy.
Age related macular degeneration is the leading cause of blindness in the developed world and third leading cause worldwide. About 196 million are projected to have AMD globally by 2020 and 288 million by 2040. We do not completely understand the pathobiology of AMD. Therefore at this time there are no FDA approved treatments for dry AMD and there a great unmet need to find treatments for dry AMD. There is a lot of ongoing research in this area . In this talk I will talk about our current knowledge based on clinical trials such as AREDS study, on diagnosis, prognosis, monitoring of disease and role of vitamins. I will also talk about some of newer agents that are in clinical trials at this time including drugs that block the complement pathways, Neuroprotective agents, statins, and cell therapies.
Jennifer K. Sun
While retinal imaging has been a part of our patient care for a number of decades, ophthalmic imaging has undergone a revolution in recent years. Improvements on color photos and fluorescein angiography as well as newer imaging modalities such as spectral domain OCT, autofluorescence, OCT angiography, and adaptive optics are now available. We will review practical uses of these imaging studies in various retinal diseases with examples to learn ways they are being used in the clinic and in clinical trials.
Alexander R. Gaudio
The majority of rhegmatogenous retinal detachments follow a well-understood pathogenetic sequence first described by Gonin over 100 years ago: progressive vitreous liquefaction, posterior vitreous detachment, retinal tear formation, and, finally, retinal detachment. Gonin also discovered that their cure depended on closing the retinal breaks. Since his time, many methods for closing the breaks have been invented and include those that work on the surface of the eyeball and those that work inside the vitreous cavity. Since rhegmatogenous retinal detachment presents infinitely variable pathology to the surgeon, choosing the optimal approach depends on careful observation and sound clinical judgment.
There is a small but significant minority of patients, however, whose retinal detachments do not have posterior vitreous detachment. These include those caused by atrophic retinal holes in lattice degeneration and those caused by retinal dialysis. In the former, vitreous traction is not an issue, and in the latter it is of minor consequence. Skillfully done scleral buckling procedures are successful in reattaching the retina permanently in close to 100% of these cases and PVR almost never occurs following uncomplicated surgery. Side effects are minimal and cataract never occurs as a result of the surgery.
On the other hand, vitrectomy in eyes with solid, non-detached vitreous is extremely challenging. Once inside the eye what does one do with this solid vitreous? One can attempt to detach the posterior hyaloid. This can be difficult to do in these young patients, and detaching it from the detached retina can cause catastrophic complications. Alternatively, one can leave cortical gel attached posteriorly and try to flatten the retina anyway. Both options are less than ideal and increase the possibility of PVR. Draining the usually very viscous subretinal fluid is hard to do by displacement and could require a posterior retinotomy to get the retina flat. Finally, cataract is inevitable.
Examples of the pathology and pathogenesis of these conditions will be presented and suggestions on their management offered.
Manju L. Subramanian
Retinal Venous Occlusive Disease is a significant cause of acute vision loss. It is often associated with patients with systemic illnesses such as hypertension and diabetes. Vein occlusions can lead to development of macular edema and neovascularization which can impact vision long term. Treatment modalities for macular edema include anti-vascular endothelial growth factor injections, steroid therapy, laser therapy, and on occasion surgical intervention. For neovascularization, anti-vegf agents, laser therapy, and surgical intervention for complicating vitreous hemorrhages and tractional retinal detachments are used. The most recent advances in therapy will be discussed.
Discovery of vascular endothelial growth factor (VEGF) and the use of anti-VEGF agents have revolutionized our management of diabetic retinopathy. Various clinical trials have shown benefit of these agents in the management of diabetic macular edema and proliferative diabetic retinopathy. However, clinical trial treatment protocols may not be easily translated and incorporated into practical day to day management of our patients in the clinic. We will review findings from key DRCRnet findings and discuss ways to optimize patient outcomes in an evidence based manner.
L. Paul Aiello
Despite remarkable advances in treatment, diabetes represents a global epidemic with diabetic eye complications remaining a leading cause of vision loss in working age adults in most developed countries. To better treat these conditions, there is a critical need for precise, readily identifiable retinal biomarkers to allow earlier, more accurate diagnosis of diabetic retinopathy, predict disease progression, determine when to start and stop treatment, understand novel pathways and develop more effective therapies. Such approaches now include identification and mapping of peripheral retinopathy lesions, retinal nonperfusion & oxygenation, disorganization of the retinal inner layers, individual microaneurysm wall & flow characteristics, novel contrast sensitivity measures, non-VEGF dependent pathways, and numerous others. Detection modalities include ultrawidefield color imaging and angiography, SDOCT, OCT-A, adaptive optics SLO, and deep learning computer algorithms. Overall, these new approaches are changing our ability to assess DR risk and monitor disease progression, and may eventually lead to a needed revision of how we grade, characterize and monitor diabetic retinopathy.