PIE POST (APVRS 2021 Edition) - DAY 3

Ocular tumors are critical to the retina... experts explain why.

The ocular impacts of COVID-19 were discussed in-depth at APVRS. Find out more...

A nuisance to our vision: floaters. What’s the best treatment option? Read more...

APVRS

Lecture Awards

A Fitting Closing to a Fruitful Congress

After a weekend of more than 20 enlightening and fascinating sessions, featuring over 100 speakers, the 14th Asia-Pacific Vitreo-Retinal Society Congress (APVRS 2021 Virtual) concluded on December 12. This was the first time the APVRS Congress has been held virtually.

Before the Congress came to an end, however, there were a few excellent final lectures, specifically those accompanying APVRS 2021 Virtual’s two major awards. The society also recognized the graduates from its leadership program and gave special recognition to some of the program’s outstanding members before moving on to the grand finale to this year’s event.

The Constable Award

Dr. Daniel Ting was this year’s recipient of the Constable Award, which is presented in honor of Dr. Ian Constable, a leader in the vitreo-retinal (VR) field and past president of the APVRS. This award is given during each year’s APVRS Congress and recognizes young VR specialists

who have significantly impacted the field of retinal research. Dr. Ting has done just that, having been recognized in numerous publications and groups.

Cont. on Page 3 >>

by Nick Eustice

Based in Singapore, Dr. Ting is an associate professor at the Duke-National University of Singapore Medical School. He is the head of artificial intelligence (AI) and digital innovation at the Singapore Eye Research Institute, and a chair of the APAO AI and Digital Standing Committee. He has been ranked first in the field of medical and health care deep learning worldwide, and seventh in the field of AI.

Dr. Ting’s Constable Lecture, entitled AI in Ophthalmology: What’s Next?, explored the concept of deep learning — an advanced form of AI where computers develop their own sets of algorithms in order to analyze data. Already a topic of considerable interest at this year’s Congress, Dr. Ting delivered a broad survey of the current state of AI, before going on to describe what he sees as being on the horizon in the world of machine learning.

The lecture began with a look at some developments in the world of AI outside the scope of ophthalmology. He pointed out the unique approaches that machine learning had brought to medical response thanks to COVID-19 in the past two years, specifically the predictive modeling assembled to track the spread of the virus and the COVID-19 dashboard by Johns Hopkins University.

Dr. Ting then described the first applications in which deep learning has been used in ophthalmology over the past five years — especially in the areas of diagnosis and cross-referencing patient data to identify biomarkers to predict retinal disease. He then went through his framework for effective coordination of teams, including medical, computing and engineering departments, along with imaging companies and industry partners, in order to utilize the tools and skill sets necessary to assemble what he calls the “brain” of a deep learning system.

Predicting the next stages we’ll see in upcoming years, Dr. Ting identified a number of important elements that he believes will have an impact. Blockchain technology, most commonly known through its use in cryptocurrency, will have a profound effect upon our capacity

to implement deep learning systems through its collective and decentralized approach to computing.

In terms of hardware, Dr. Ting noted that 5G communications will enhance our capacity to move data quickly and wirelessly, while quantum computing promises to increase the analytical power of our data centers exponentially. Lastly, he suggested that the metaverse — our online world of social interaction — could play a key role in how we interact with AI in the future.

The International Award

Next up in the closing ceremony came the International Award and its accompanying lecture. This award is also presented during each year’s Congress and recognizes individuals from outside of the Asia-Pacific region for their contributions to the global pool of knowledge, and who have made a sizable impact within the region, as well.

The 2021 recipient of the International Award was Dr. R.V. Paul Chan, chair of the Department of Ophthalmology and Visual Sciences at the University of Illinois in Chicago. Dr. Chan has dedicated his life to developing programs to prevent blindness in children with retinopathy of prematurity (ROP). He has trained and collaborated with many of the ROP leaders in Asia, and

has led programs for the development of ROP screening there.

Dr. Chan’s International Award Lecture poignantly dealt with this work he has done in developing diagnoses for this major global problem in ophthalmic health. Entitled Technology and the 3rd Epidemic of ROP: Opportunities to Improve Outcomes and Access to Care, his lecture described his experiences in helping to extend ROP diagnostics and treatment to underserved countries such as Nepal, Mongolia, the Philippines and India.

These projects made abundant use of technologies which had been previously unavailable in these countries. As these countries are among the most hard-hit by ROP in the world, this technology was, and remains, very badly needed there.

Dr. Chan’s work has indeed been world-changing for countless young people.

A harmonious ending

Following the two key-note lectures, several contributors for outstanding papers, posters and videos presented during the Congress were recognized. In addition, the Congress chairs congratulated the graduates of the APVRS’s Leadership Development program.

The ceremony had a special, unannounced surprise at the end: two performances from the International Retinal Band. This band, comprised entirely of retinal specialists from across the Asia-Pacific region, joined together in an online ensemble to entertain the congress with two musical performances. The first section of the band played John Lennon’s classic “Imagine,” which was followed by a second group performing Simon & Garfunkel’s “Scarborough Fair.”

While the comments bar within the meeting had been active with questions throughout the Congress, it positively lit up during these performances, with many words of encouragement and appreciation throughout, followed by many calls for an encore thereafter!

It was a fine ending to an excellent Congress, and the chairs concluded with an invitation to join them for APVRS 2022 in Taipei. We look forward to seeing you there!

Is it a tumor?! Diagnosis, Management and Treatment in Ocular Oncology

by Jillian Webster

The study of ocular oncology is in constant development, with new studies and diagnostic techniques underway. And as the identification and classification of tumors becomes more advanced, there will also be an expansion of treatments.

New approaches to retinal hemangioblastoma

Dr. Carol Shields, Wills Eye Hospital (Philadelphia, Pennsylvania, USA), opened this symposium on day 1 of the 14th Congress of the Asia-Pacific Vitreoretina Society (APVRS 2021 Virtual). She discussed the different types of tumors that occur in the fundus including, retinal and choroid.

Hemangioblastoma is a form of retinal tumor that is characterized as benign red-orange mass. It is often associated with subretinal fluid, exudation, vitreous fibrosis, retinal detachment and poor visual acuity. There are also some associated risks for Von Hippel–Lindau (VHL) disease that decrease with age. If the patient has multifocal tumors they will develop VHL, retinal hemangioblastoma is generally the first sign of VHL.

Dr. Shields explained that the management of retinal hemangioblastomas is complex and may include laser photocoagulation, cryotherapy or resection, among other treatments. Screening after birth and early treatment is the best way to fight this condition.

Intra-arterial chemotherapy as primary treatment for advanced unilateral retinoblastoma

“Retinoblastoma is the most common primary intraocular cancer in children,” began Dr. Tingyi Liang, Shanghai Jiaotong University (China).

Dr. Liang says that systemic chemotherapy is the most common treatment for this type of melanoma. Over the past 20 years, Dr. Liang has been working on a new type of infusion chemotherapy. In his tests he was able to conclude that intra-arterial chemotherapy is an effective treatment for advanced unilateral retinoblastoma and shows significant tumor reduction with minimal side effects.

More testing is needed in the future, but Dr. Liang’s work is encouraging.

MRI in retinoblastoma and melanoma

Imaging is important when determining the extent and severity of any cancer, stressed Pim de Graaf, a radiologist with the European Retinoblastoma Group and European Retinoblastoma Imaging Collaboration.

Once the characteristics of the disease are identified, then proper treatment can be determined. MRI, though not a perfect method, when used with proper protocols and resolution, aids in the planning of treatments and the prevention of potential vision and life-threatening developments in retinoblastoma.

Dr. Jan-Willem M. Beenakker, Leiden University Medical Center (the Netherlands), also discussed the benefits of MRI in melanoma imaging. He pointed out that the location of a tumor may

affect its optical visibility and therefore, it’s necessary to use other methods — such as MRI — to accurately represent the extent of the disease.

OCT in the diagnosis of intraocular tumors

During her talk, Dr. Emil Say, Storm Eye Institute Medical University (Charleston, South Carolina), focused on the diagnosis of small indeterminate yellowwhite lesions in the fundus using OCT.

OCT allows for greater detail in tissue origin and lesion configuration. Dr. Say acknowledged the limitations of OCT and the need for further clinical trials; however, she emphasized the value of OCT in visualization of yellow-white lesions and deterioration prevention.

Liquid biopsies in ocular oncology

Dr. Jesse L. Berry, University of Southern California (Los Angeles), began by explaining the common way retinoblastoma is diagnosed.

He said that retinoblastoma is diagnosed on clinical features alone and not biopsied due to mortality risks. The lack of biopsies implies certain limitations in diagnostics and treatment plans.

However, the advance in liquid chemotherapy has given way to the idea of liquid biopsy. Liquid biopsies are a mixture of cellular and noncellular components that are a source of tumor derived molecules. This development will allow for better diagnostic and treatment plans in the future.

Overall, ocular oncology continues to make leaps forward in research and treatment. This symposium demonstrates the developments of diagnostic and treatment tools for intraocular tumors and the prevention of blindness.

Ocular Inflammation and COVID-19

Inflammation of the eye can have a variety of different causes, some more serious than others. It can occur as an allergic reaction, or due to physical injury or trauma. A number of conditions specific to the eye can cause inflammation, and so can a variety of other infections throughout the body. Many diseases can manifest in the eye, and as new diseases present themselves, it is very valuable to recognize correlations between ocular inflammation, as well as other symptoms within the eye, and those new illnesses.

It should come as no surprise, then, that we begin to wonder about what symptoms arise due to the most talked about disease of the past two years, COVID-19. This leads us to a number of questions posed by Dr. Rupesh Agrawal in his presentation, Ocular Manifestations of COVID-19: What Is Real, What Is Spurious?

Speaking during the Uveitis & Ocular Inflammation Management and Pearls for Diagnosis symposium on the first night of the 14th Asia-Pacific Vitreoretina Society Congress (APVRS 2021 Virtual), Dr. Agrawal sought to address a number of meaningful concerns on the topic of COVID-19. What are the ocular manifestations of COVID-19, and are the ones which we may have heard about real, or spurious? Do any retino-choroidal or microvascular changes take place as a result of the disease? Can COVID-19 be transmitted through tears and conjunctival secretions? And if so, what are the proposed mechanisms of ocular infection or viral shedding in tears?

Ocular symptoms

In addition to the usual respiratory issues typical of the disease, there have been numerous reports of symptoms within the eyes of COVID-19 patients, including many similar to those exhibited in cases of conjunctivitis. These include epiphora (unusually abundant tearing) hyperemia (excessive blood flow) and chemosis (swelling of the optical membrane).

by Nick Eustice

In a study of over one thousand COVID-19 patients in 2019 at the start of the pandemic, ocular symptoms were observed in only nine patients—less than one percent of those observed. No conjunctival swabs or tear sampling was conducted, and no patients were recorded as having seen an ophthalmologist. This earliest of studies does not necessarily reflect a lack of ocular manifestations, however, and may rather be due to the immediacy of other, more threatening symptoms.

Later, more in-depth studies have shown that the choroid was thicker in all regions in COVID-19 patients. This suggests that an underlying inflammation of the choroid, which Dr. Agrawal suggests could result in stromal edema, may be a common symptom of COVID-19. Not only does this reveal a new threat to patients’ eyes as a result of this disease, but it also allows for another avenue of detecting the condition in the first place.

Dr. Agrawal also noted that in this study, no significant relationship was observed between the duration of the disease and the changes in choroidal structure. Thus, ocular inflammation may accompany COVID-19 for a longer or shorter time than other symptoms can be detected.

COVID-19 in patients’ tears

Turning to the question of COVID-19 transmission via tears, Dr. Agrawal began by explaining the need for more data on this subject. While much of the population primarily considers face masks and social distancing to be the

primary defense against COVID-19 infection, a host of unique issues would be presented to eye care professionals if the virus could be transmitted through a patient’s tears. Personal protective equipment (PPE) and infection control protocols would need to be addressed at all levels, from intraocular surgery all the way down to outpatient procedures in the eye clinic. Additionally, tear sampling could be used, in such a case, as a potential adjunct for diagnosis of COVID-19 infections.

How might viral shedding occur in a patient’s tears? Dr. Agrawal introduced a number of proposed theories. It is possible that the virus could migrate from an upper respiratory infection through the nasolacrimal duct, thereby making its way into tears. In such a case, the reverse condition could also be true, with the disease being transmissible into a patient via the nasolacrimal ducts. Alternatively, there is the possibility of hematogenous infection of the lacrimal gland, which could also result in viral presence in tears.

While these possibilities do exist, Dr. Agrawal cited the findings of a study conducted by Seah et al. in Singapore. A sampling of 17 COVID-19 patients who showed no symptoms within the eye were tested for the virus using tear samples over a period of 20 days. While nasopharyngeal swab samples continued to show positive results in all of the patients within this study, all tears showed no presence of the virus.

Conclusions

Dr. Agrawal closed his presentation by saying that these studies have shown themselves to be less conclusive than we would like. He proposed that a dedicated ophthalmological assessment of COVID-19 patients be conducted, particularly among those presenting ocular signs and symptoms. For the health of patients and those around them, we must consider the so far undiscovered means of COVID-19 transmission, and its possible impact on the health of their eyes.

Updates in Retinal Imaging

Imaging is used to identify and treat a wide range of retinal diseases. During a Retinal Imaging symposium at APVRS 2021, speakers addressed a number of imaging modalities with an emphasis on use in clinics as a way to ascertain functional correlation.

Updates from the APOIS PCV Workgroup

The lectures began with Dr. Kelvin Ero, Singapore National Eye Center. He explained the goals of the Asia-Pacific Ocular Imaging Society (APOIS) are “to advance the research and education of scientific knowledge relevant to ocular imaging, with a focus on common Asian ocular disease.”

He emphasized the use of non-ICGA (indocyanine green angiography) features in the management of polypoidal choroidal vasculopathy (PCV). He explains the diagnosis of PCV in suboptimal responses and recommended photo dynamic therapy (PDT). Optical coherence tomography (OCT) can be used to delineate PDT, said Dr. Ero.

Multimodal classification of central serous chorioretinopathy

Dr. Jay Chhablani, University of Pittsburgh (Pennsylvania, USA), then spoke about multimodal imaging-based central serous chorioretinopathy (CSCR) classification.

He pointed out that there have been some discrepancies in classification of CSCR, where the graders were not in agreement. The advantages of multimodal imaging techniques are therefore more valid and reproducible —

by Jillian Webster

and therefore, this method is better for establishing treatment guidelines.

Microaneurysm, macroaneurysm and neovascularization in OCTA

Dr. Suqin Yu, Shanghai General Hospital (China), discussed microaneurysm, macroaneurysm and neovascularization in the eye as interpreted through optical coherence tomography angiography (OCTA).

OCTA is affected by the structure and size of the aneurysm. By interpreting the size, location, shape, B scan, and en face of the aneurysm, ophthalmologists can increase their ability to study these ocular issues and thus, make way for more advancements in treatment.

New insights in Coats disease

Dr. Min Kim, Gangnam Severance Hospital, Yonsei University College of Medicine (Seoul, Korea), discussed multimedial imagining in response to Coats disease.

Coats disease, or congenital idiopathic retinal vasculopathy was initially described in 1908 and is characterized by retinal vascular telangiectasias and exudative retinopathy. By using multimodal imaging, doctors are able to monitor subtle vascular changes in eyes. This has allowed ophthalmologists to enact more effective treatment of the condition.

A predictive factor for recurrent PIC

Dr. Feng Wen, Zhongshan Ophthalmic

Center (China), said that punctate inner choroidopathy (PIC) is characterized by yellowish lesions at the fundal posterior pole, without intravitreal inflammation or infection.

Using multimodal imaging, Dr. Wen said that patch hyperfluorescence can be identified and further inflammation can be treated resulting in better management of the disease. Because PIC is common, it is important for clinicians to use multimodal imaging to identify, intervene and follow-up with all patients showing symptoms.

Retinal vasculopathy in COVID-19

Dr. Alessandro Invernizzi, Luigi Sacco Hospital, University of Milan (Italy), discussed the impact the spread of COVID-19 has had on the world of ophthalmology.

He points out the COVID-19 was not just a respiratory disease, but also had a number of ophthalmological implications. Dr. Invernizzi explained that retinal vessel analysis shows that COVID-19 can impact retinal vasculature. He suggested that ophthalmologists pay attention to the potential of long lasting structural alterations in patients that have experienced COVID-19 infection.

Widefield imaging in inflammatory disorders

Dr. Thanapong Somkijrungroi, Chulalongkorn University (Bangkok, Thailand), discussed his personal use of multimodal retinal imaging. He demonstrated the benefits of widefield imaging in diagnosis of various ocular conditions and said that this type of imaging provides opthamologists with better opportunities for diagnosis and treatment.

Going forward

Presenters in this symposium have made the importance of imaging in diagnostics clear — and the retinal imaging developments highlighted here show this increased functionality of imaging methods and continuing improvements in identification and treatment.

Treating Floaters

YAG versus Vitrectomy

by Nick Eustice

Although vitreous opacities, commonly called floaters, are frequently seen as more of a nuisance than serious condition, they can sometimes cause serious visual obstruction. When this is the case, two treatment methods are commonly used. YAG vitreolysis can be used to break up the opacities within the eye using a laser, in a largely non-invasive, but potentially dangerous procedure. Alternatively, a pars plana vitrectomy (PPV) can be performed, whereby the vitreous in the eye is replaced, thereby removing the opacities entirely.

Both methods are somewhat commonplace, with some doctors preferring one technique over the other for a variety of reasons. But what are the advantages and disadvantages of both treatments? Seeking to answer this question, Dr. Netan Choudhry presented his lecture entitled Vitreous Opacities: Yag Vitreolysis vs. Vitrectomy during the Pearls for Surgical Retina symposium at the Asia-Pacific Vitreo-retina Society Congress (APVRS 2021).

Those pesky vitreous opacities

Dr. Choudhry began by briefly explaining what vitreous opacities are. The vitreous

within the eye is 99% water and 1% solid elements, which are made up principally of hyaluronic acid bound to collagen. Over time, unbound collagen adheres to itself within the vitreous, creating clumps of varying size. When these are small enough, they are usually not noticed at all. When they are large enough to obstruct vision, however, they have been shown to impair a patient’s reading vision, microperimetric function, contrast sensibility, and overall quality of life.

As the effects of vitreous opacities have become more widely understood, various methods have been used to assess these; B-scan ultrasound, vitreoscopes, or other clinical examinations have been used. What has become far and away the most common method of evaluation, however, is optical coherence tomography (OCT).

When evaluating vitreous opacities for treatment, it is important to consider various factors. Dr. Choudhry says the first of these is that the opacities must be symptomatic: They must be a cause of constant visual disturbance, constituting an impairment of the activities of daily living. They must be long-standing, rather than an acute, temporary condition.

Floaters must be visible on observation using OCT scans, and only at that time can we consider one treatment method or another.

YAGi vitreolysis is preferable in a number of cases. It is non-invasive, and is a relatively safe option for the treatment of visually significant vitreous opacity. It is ideally suited to treating floaters that are focal singular, situated within the central visual axis, and visible on a contact lens exam so that they can be lasered. Floaters to be treated with YAG vitreolysis should be located at the anterior or mid-vitreous, and not close to the retina.

On the other hand, PPV is preferable in opposite cases. Where there are numerous and diffuse opacities that nonetheless obstruct a patient’s sight, a vitrectomy is the preferred option. Where floaters are non-centric, incompletely visible on contact lens exam, or existing in the posterior third of the vitreous, where retinal damage from the laser would be a risk, here a vitrectomy is also a far better alternative.

Both treatment options have their advantages, and drawbacks as well. Dr. Choudhry reminds us that one is usually better suited to a given situation. Where YAG vitreolysis is possible, it is often preferred as the less-invasive method. But in situations where it can be dangerous, or simply ineffective, the vitrectomy is the better, often only choice.