April 24, 2020 Conference
Session 1. New Drugs in Ophthalmology: From Drop to Drips
Professional Practice Gaps: Feedback from NEOS members and Program committee review identified that practice gaps included lack of familiarity with the rapidly expanding treatment options for glaucoma and dry eyes and lack of knowledge about the novel biologic agents available for the treatment of non-infectious uveitis.
Program Objectives. The content and format of this educational activity has been specifically designed to fill the practice gaps in the audience’s current potential scope of professional activities by:
1. Becoming familiar with the new agents available for treatment of glaucoma and dry eyes.
2. Understanding the differences between previously available and newly available anti-VEGF agents for the treatment of retina and choroidal vascular disease.
3. Becoming familiar with new agents that are currently available for the treatment of non-infectious uveitis.
Evaluation.Please submit your session evaluation after you complete the final presentation you plan to attend.
Mary K. Daly
Endophthalmitis is an uncommon but potentially devastating complication of cataract surgery, with the primary source of infection being the patient’s own flora.¬¬ Reported rates of postoperative endophthalmitis from cataract surgery range from 0.04%-0.29%. In order to decrease the risk of endophthalmitis, prophylactic measures are taken. The use of Povidone-iodine has been shown to be one of the most effective prophylactic treatments in the prevention of post-cataract endophthalmitis. In addition, topical antibiotics are used perioperatively for prophylaxis against infection. Topical fluoroquinolones have been widely used as prophylaxis in cataract surgery, with fourth generation fluoroquinolones showing a significantly decreased incidence of endophthalmitis compared to prior generations. Several studies have also shown a decreased incidence of endophthalmitis with the use of prophylactic intracameral antibiotics for phacoemulsification. However, in the era of developing antibiotic resistance, there is growing concern of overutilization of newer broad-spectrum antibiotics, especially for prophylaxis. With the use of intracameral antibiotics, there are potential issues with sterility, errors in dilution, or the inadvertent use of preserved formulations leading to Toxic Anterior Segment Syndrome (TASS). Additionally, many of these newer antibiotics are costly, and it is important to evaluate whether the higher costs associated with these antibiotics contribute to quality of care.
Z. Katie Luo
There are 20 million cataract surgeries being done annually worldwide. Despite the high success rate of the procedure itself, poor adherence to the post-operative treatment regimen hinders many from timely recovery and increases the risk of vision-threatening complications. This presentation summaries current development in various intra-operative and post-operative drug delivery strategies, all of which aim at the removal of patient compliance from the equation, therefore optimize and standardize the healing process.
Topical medications remain the mainstay of current glaucoma management, being utilized as first-line therapy for most patients. This presentation will review all of the commonly-used topical glaucoma medications. Each medication will be reviewed in terms of indications, mechanisms of actions, effectiveness, side effects, and accessibility within the health care system. Special emphasis will be paid to the newest topical medications that have come to market in the past 2 years: latanoprostene bunod, netarsudil mesylate, and the combination agent latanoprost/netarsudl.
Quan Dong Nguyen
Diabetic retinopathy is the leading cause of vision loss in working-age adults. Meta-analysis of 4 similar randomized clinical trials involving RBZ in eyes with DR and DME (patients with prior-PRP were excluded) – RIDE and RISE, DRCR.net Protocols I and T – was performed to determine the most optimal window of maximum efficacy for treating diabetic retinopathy.
Dry eye is prevalent in our modern society with estimates that it affects 16 million people in this country. What is more, our patients are seeking help as they spend their day in climate controlled work places, staring at screens, all of which takes its toll on comfort and vision. Advances in research, like the TFOS DEWS II report, have broadened our understanding of the complex nature of dry eye to include the role of inflammation, the loss of tear film homeostasis, neurosensory abnormalities, and the importance of the meibomian glands and eyelids. This talk will cover newer therapeutic agents, both drops and devices, that address dry eye as well as where they fit in to this new paradigm. Some of these drops are new molecules, others are familiar to us, like cyclosporin, but come with innovations in delivery systems that promise improved penetration, efficacy, and lower side effect profiles. Evaporative dry eye, meibomian gland disease, and blepharitis are getting center stage attention with the development and expansion of devices to treat the eyelids. Less innovation is happening in ocular allergy treatment, but this talk will cover our current therapeutics and an update on newer agents.
Most drugs have been traditionally delivered to the front of the eye by ophthalmic solutions or ointments. Because a means of sustained drug delivery to the eye may improve patient adherence and can possibly be more effective than drops and ointments, there has been an increased interest in developing sustained drug delivery to the eye. Many approaches have been described, but there are some unique challenges associated with ophthalmic drug delivery that may limit their effectiveness and patient acceptance. Collagen shields and pilocarpine-containing, polymermembrane unit (Ocusert) were two of the first products available for sustained ocular drug delivery. Decades later, three new products have been FDA-approved for sustained drug delivery to the front of the eye over the last several years. We will review the use of the FDA-approved products.
Quan Dong Nguyen
Uveitis is a spectrum of inflammatory disorders characterised by ocular inflammation and is one of the leading causes of preventable visual loss. The main aim of the treatment of uveitis is to control the inflammation, prevent recurrences of the disease, and preserve vision, while minimizing the adverse effects associated with the therapeutic agents. Initial management of uveitis relies heavily on the use of corticosteroids. However, monotherapy with hi-dose corticosteroids is associated with side effects and cannot be maintained long term. Therefore, steroid-sparing agents are needed to decrease the burden of steroid therapy. Currently, the therapeutic approach for non-infectious uveitis (NIU) consists of a stepladder strategy with the first line option being corticosteroids in various formulations followed by the use of first, second, and third line agents in cases with suboptimal steroid response. Unfortunately, the agents currently at our disposal have limitations such as having a narrow therapeutic window along with their own individual potential side-effect profiles. Therefore, research has been targeted to identify newer drugs as well as new uses for older drugs that target specific pathways in the inflammatory response. Such efforts are made in order to provide a targeted and safer therapy with reduced side effects and greater efficacy. Several specially designed molecular antibodies are currently in various phases of investigations that can potentially halt the inflammation in patients with NIU. In this presentation, we will provide a comprehensive overview of the current and upcoming therapeutic options for patients with NIU.
Session 2. Retinal Detachment: Diagnosis, Management, and Challenges.
Professional Practice Gaps: Retinal detachment has not been a theme in NEOS in over 5 years, and audience has been seeking an overview of various types of retinal detachment and their management.
Program Objectives: The content and format of this educational activity has been specifically designed to fill the practice gaps in the audience’s current potential scope of professional activities by:
1. Demonstrating the surgical principles in adult and pediatric retinal detachment repair.
2. Discussing the challenges Vitreoretinal surgeons face in diabetic tractional retinal detachment and proliferative vitreoretinopathy (PVR)-associated recurrent retinal detachment.
3. Familiarizing the audience with special techniques utilized by Vitreoretinal surgeons in difficult retinal detachment repairs.
Evaluation.Please submit your session evaluation after you complete the final presentation you plan to attend.
Will give introduction on Drs. Richard Watson, Robert Millay, Anthony Joseph, David Lally, Caroline Baumal, and Kristen Nwanyanwu
Vitrectomy surgery is the most common treatment for rhegmatogenous retinal detachment. This lecture will discuss the diagnosis of retinal detachment and the steps to take after diagnosis including the timing of intervention and how to prepare a patient for vitrectomy surgery. The steps of vitrectomy surgery will be discussed along with video demonstration. This talk is directed to all ophthalmologists and is a good review for vitreoretinal surgeons.
Scleral buckling is the traditional method of retinal detachment repair. In spite of the notable shift towards vitrectomy or vitrectomy with scleral buckle for retinal detachment , buckling alone still has great utility in a variety of retinal detachment settings. We will discuss principles of scleral buckling, the importance of excellent evaluation of the peripheral retina with documentation of findings and development of a preop battle plan and the steps in a buckle especially drainage of subretinal fluid. The place of buckling today in the vitreoretinal surgeon’s arsenal will be deliberated upon. It is best to have many arrows in ones quiver and know which one will fly true in each specific surgical setting.
Introduced in 1986 as an alternative to scleral buckle and pars plana vitrectomy for the repair of primary rhegmatogenous retinal detachment, pneumatic retinopexy remains an important tool for retina specialists. When properly utilized, it can offer lower risk and more rapid visual recovery compared to surgical alternatives. We will review the factors that ophthalmologists must consider when determining if pneumatic retinopexy is appropriate for their patients. We will also discuss the procedure in detail including keys to successful outcomes.
-PVR definition and incidence
-Anatomical and functional success in recurrent RD repair with PVR
Where are we today in the management of PVR?
-Timing of intervention
-MembraneBlue, triamcinolone, ICG stains
-Tamponade: Gas versus Silicone Oil
Where are we going in the future with managing PVR?
-Adjunctive treatments to prevent cellular proliferation
-Intravitreal methotrexate (Aldeyara Therapeutics)
-Development PVR grading schemes
-Genetic, imaging, and biochemical markers
Medium-term Perfluoro-n-Octane for Inferior Retinal Detachments, Giant Retinal Tears, and Macular Patch Graft
Steve Charles MD
I. Medium-term Perfluoro-n-Octane (PFO) Without Scleral Buckle for Inferior Retinal Detachment
A. Medium-term PFO is off label.
B. No supine or face-down positioning; patient can sit, stand, fly, drive, and work.
C. Slow, safe posterior vitreous detachment (PVD) over 14 days; no need for aggressive PVD induction associated iatrogenic retinal break risk in young myopes without PVD
D. No induced refractive error, unlike buckles; ideal after cataract and refractive surgery
E. Unlike scleral buckles; strabismus, pain, no ocular surface disorder (poor conjunctival closure), or corneal or conjunctival damage (future glaucoma surgery)
F. Effective in phakic, IOL, or aphakic eyes
G. Remove PFO in 14 days
H. See Sigler EJ, Randolph JC, Charles S. Foreign body response within postoperative perfluoro-n-octane for retinal detachment repair. Retina 2014; 34(2):237-246; Sigler EJ, Randolph JC, Calzada JI, Charles S. 25-gauge pars plana vitrectomy with medium-term postoperative perfluoro-n-octane tamponade for inferior retinal detachment. Ophthalmic Surg Lasers Imaging. 2013; 44(1):34-40.
II. Medium-term PFO for Inferior, Nasal, or Temporal Giant Retinal Tears (GRTs)
A. Use medium-term PFO for inferior, nasal, or temporal GRTs to prevent slippage.
B. Inject PFO over the optic nerve using a dual bore cannula and viscous fluid control (VFC) at 8 psi; retract tip during injection, keeping tip at PFO–BSS interface to ensure a single PFO bubble.
C. Apply confluent endolaser to break, extend to ora at both ends of giant tear.
D. No scleral buckle
E. Topical difluprednate b.i.d. unless steroid responder
F. Remove PFO in 14 days.
III. Superior GRT
A. PFO–gas exchange or PFO-silicone oil exchange for superior GRT. Oil if proliferative vitreoretinopathy.
B. Chandelier illumination; VFC with silicone injection cannula in one hand, extrusion cannula without soft-tip in the other hand
C. Use VFC at 80 psi to inject oil through a sclerotomy cannula, not an infusion cannula, with short, thin-walled, low-resistance cannula
D. Keep extrusion cannula tip at oil or gas interface, with PFO in periphery to avoid slippage during exchange by removing BSS, subretinal fluid, and liquid vitreous before PFO.
E. Move focus down to follow cannula tip as exchange proceeds to optimize view of interface.
IV. Autologous Macular Patch Graft
A. Developed by Tamer Mahmoud
B. Move graft from donor location to macular hole “under” PFO with DSP internal limiting membrane forceps to prevent scrolling and inversion; do not lift leading edge of graft.
C. PFO provides much better graft oxygenation than silicone oil (Steve Charles) because of higher oxygen solubility and extraction ratio; vitrectomy decreases viscosity 800X, thereby increasing partial pressure of oxygen by 12 mmHg; PFO enables graft oxygenation from anterior surface, not just choriocapillaris.
D. Remove PFO in 7 days. Grewal DS, Charles S, Parolini B, Kadonosono K, Mahmoud TH. Autologous retinal transplant for refractory macular holes: Multicenter International Collaborative Study Group. Ophthalmology,
Increased oxygen diffusion post-PPV because of 800X viscosity decrease.
V. PFO vs. Oil Oxygen Transport
A. “PFCs can hold as much as 3 times the oxygen as human blood.”
B. Lower total oxygen carrying capacity observed for perfluorinated fluid emulsions is balanced by their much higher oxygen extraction efficiencies. Adapted from Krafft MP, Riess JG. Perfluorocarbons: life sciences and biomedical uses. J Polym Sci A Polym Chem. 2007; 45:1185-1198.
C. “Silicone oil hinders oxygen mass transfer compared to air-water system. Decreases of kLa up to 25% have been noted.”
Management of retinal detachment is the pediatric age group requires special considerations. The etiology of the detachment should be considered While adults most often present with rhegmatogenous retinal detachment (RRD), the pathogenesis often differs in children and may include tractional progressive vitreoretinopathies and genetic syndromes. Systemic evaluation, examination under anesthesia and bilateral ocular intervention may be necessary. Delay in diagnosis is common with signs of chronicity affecting the success of surgical repair. Special considerations are needed in every step of the assessment including pre-operatively with family counselling, intraoperatively with surgical adjuvants and equipment requirements and postoperatively with continued retinal examinations and visual rehabilitation.
Failure Modes in Retinal Detachment Surgery
Steve Charles MD
I. Failure Mode
1. Untreated retinal breaks / holes / tears
2. Residual vitreous traction
B. Biological: Proliferative vitreoretinopathy (PVR)
1. Following appropriate surgery
II. A Common Cause of Untreated Retinal Breaks and Residual Traction Is Poor Visualization
Tradeoff: Combined phaco often results in miosis, which may require iris hooks, which increase inflammation; inflammation contributes to PVR.
B. Posterior capsular opacification
Tradeoff: Intraoperative capsulectomy results in IOL fogging after fluid–air exchange with all IOL materials, not just silicone; never remove central anterior vitreous if prior YAG capsulectomy.
C. Use wide-angle visualization and/or scleral depression to ensure examination of peripheral retina.
III. Conceptualization Is a Key Aspect of Visualization
A. Highest point of detachment may help find breaks (Lincoff rules).
B. Concentric demarcation lines may point to retinal break(s).
C. Patient’s evolving “shadow” history may help locate initial retinal detachment and breaks.
D. Localized pigmentation often indicates break location because of retinal pigment epithelium (RPE) apical process elongation and melanin migration (adaptive surface area increase to absorb subretinal fluid [SRF])
E. Ends of lattice degeneration is common break location.
F. In an optical effect known as “Schlieren,” SRF may stream from break(s) during peripheral vitreous removal; it is not just a “core vitrectomy.”
G. Confluent laser to “suspicious” areas after internal drainage of SRF combined with fluid–air exchange often helps find breaks.
IV. Visualization of Residual Vitreous Traction
A. Residual vitreous is easily seen during trans-hole or drainage retinotomy aspiration of SRF combined with fluid–air exchange.
B. Remedy: Vitrectomy “under” air allows visualization of residual vitreous traction because of optical effect of vitreous interface with air (specular reflection / sheen and refractive effects).
C. Marked, localized elevation of equatorial retina usually indicates residual vitreous traction.
V. Combining Scleral Buckling With Pars Plana Vitrectomy Is Not the Answer
A. No randomized clinical trial evidence that combining a buckle with vitrectomy increases success rates compared to pars plana vitrectomy alone.
B. New breaks and PVR often occur posterior to encircling bands; even broad buckles.
C. Buckle complications:
1. Induced axial myopia (unhappy patient if prior LASIK, PRK, or refractive cataract surgery)
2. Increased phorias and tropias
3. Longer operating times, increased labor cost, more general anesthesia use, pain
4. Ocular surface disorder from poor conjunctival closure
5. Slight ptosis from levator aponeurosis damage
6. Conjunctiva, Tenon, and episcleral scarring cause problems if subsequent glaucoma surgery is required.
7. Buckle extrusion
VI. Rows of 360° Laser Are Not the Answer
A. Increased inflammation; possibly increased PVR
B. Toroidal (donut) detachment between equatorial or post-equatorial laser and ora serrata
C. Increased PVR
D. Anterior segment neovascularization from VEGF produced by chronically elevated anterior retina
E. Breaks missed at surgery and/or new breaks often occur between laser spots or posterior to laser spots.
VII. Iatrogenic Causes of PVR
A. Excessive retinopexy; both quantity / area of applications and intensity
B. Cryopexy causes more inflammation and PVR than laser does.
C. Too little time between surgical procedures; do not operate on “hot” eyes.
VIII. Do Not Leave Capsule for Subsequent IOL Insertion If Lensectomy Performed
A. Capsule becomes adherent to iris and residual anterior vitreous.
B. IOL insertion never happens.
C. Concave iris
D. Fixed pupil
E. Probable increased anterior PVR secondary to increased inflammation and capsule-cortex-peripheral vitreous adherence.
F. Inferior iridectomy closure in silicone oil cases secondary to fibrosis unless total capsule removal with forceps.
IX. Confluent Laser Retinopexy Is Better Than Spots
A. Spots are an outdated idea apparently related to cryo and diathermy retinopexy because these probes cannot be moved while energy is applied.
B. Endolaser produces a top-hat (square) beam profile that produces hot center and cold surrounding tissue heating, and therefore nonuniform healing and adherence.
C. Spots produce undesirable overlapping (excessive damage) or underlapping (adherence gaps enabling SRF leakage).
D. Moving the laser while surrounding retinal breaks utilizes motion blur to produce more uniform lesions without gaps.
X. Critical Elements of Successful Surgery
A. Must use wide-angle visualization
B. Must use scleral depression if non-contact wide-angle visualization
C. Remove vitreous traction from flap of all flap tears and anterior to all breaks.
D. Remove as much peripheral vitreous as possible without damaging clear lens.
E. Surround all breaks with moderate intensity confluent laser, not rows of spots.
F. Do not hesitate to remove lens or IOL if poor view.
G. No combined phaco
H. Do not leave capsule if lensectomy.
I. No 360° laser
J. No buckles
K. Make use of medium-term perfluoro-n-octane PFO for inferior retinal detachments (PFO causes gentle PVD creation over 2 weeks in young myopes without PVD; remove posterior vitreous cortex when PFO removed).
L. If “hot” eye, use silicone oil and perform laser later.
M. Do not remove central anterior vitreous if prior YAG.
Dr. Nwanyanwu will illustrate the management of tractional retinal detachment in a case-based presentation. She will present the pathophysiology of how tractional retinal detachment develops, indications for repair, preoperative management, surgical techniques, and outcomes.