APVRS 2022 - Taipei, Taiwan - Issue 3

Improving Sight, Not Just Visual Acuity

A/Prof. Andrew Chang, the APVRS 2022 Tano Lecture Awardee, highlights macular structure and function assessment in surgical vitreomaculopathy in his lecture

Each year since 2009, the Asia-Pacific Vitreo-retina Society (APVRS) selects an outstanding retina specialist to be awarded the APVRS Tano Lecture Award. And this year is no different.

This year, the award finds its rightful place in the hands of highly acclaimed vitreoretinal surgeon A/Prof. Andrew Chang from Australia, who has shown exemplary leadership and made significant clinical contributions in advancing training education and treatment of retinal diseases in the Asia Pacific region and beyond.

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Tano Lecture commends an individual of over 45 years of age in the Asia-Pacific region for exemplary leadership and significant contributions in advancing the understanding, diagnosis, and treatment of vitreoretinal diseases.

Advancements in vitrectomy technology

Delivering the Tano Lecture on the second day of the 15th APVRS Congress, A/Prof. Chang noted that we have seen great advancement in vitrectomy technology that allows the management of patients not only in the operating room but also perioperatively.

He mentioned that it is possible to classify the traction of the macula now — be it vitreomacular adhesion, vitreomacular traction, or full-thickness macula hole.

Optical coherence tomography (OCT) technology also allows better discernment of the macula hole, and the intraoperative OCT enables surgeons to deal with vitreoretinal pathology in real time.

“Most of the vitreoretinopathies arise from the anomalous posterior vitreous detachment where the vitreous separates off but just remains adherent to the macula area, and this leads to a range of pathologies,” A/Prof. Chang said, adding that while most cases of vitreomacular

traction (VMT) resolve spontaneously, sometimes it may not.

He described a tool that he has been using for about seven years — the macular integrity assessment (MAIA) microperimetry, which allows highdensity assessment of macular function, combines SLO with eye-tracker, and allows the assessment of 37 points within the central 10 degrees of the retina.

Macular perimetry provides valuable and accessible objective information for the clinician in the decision-making and management of patients with surgical maculopathies, including determining when to perform surgery for epiretinal membrane and myopic maculopathy and evaluating the postoperative care of macular surgery.

He noted that in cases of epiretinal membrane, macular microperimetry allows the evaluation of visual function, predicting prognosis after surgery, and postoperative monitoring. And in terms of myopic maculopathy, MAIA can give information about the progression of schisis.

Improving sight and function

He also shared cases in which he used macular perimetry to treat his patients effectively.

“Macular perimetry is a clinically accessible tool,” A/Prof. Chang shared.

“Surgery decision-making depends on the structural changes imaged by OCT, as well as function measured by macular perimetry.”

He added that MAIA demonstrated improved macular function after surgery consistent with increased visual acuity (VA) and decreased central macular thickness (CMT). “We can track changes precisely to location, which is really useful,” he noted.

In addition, he shared that patientrelated outcome measures are becoming increasingly important. “We must actually prove to the funders of what we do that we are actually improving sight, not just visual acuity, but in terms of function as well.”

“There are potential predictive markers following surgery using perimetry, and I am hopeful that we might be able to correlate structure with function using artificial intelligence,” he said, concluding his talk.

Get to Know A/Prof. Andrew Chang

A/Prof. Andrew Chang is a vitreoretinal surgeon and ophthalmologist who holds an academic appointment of Clinical Associate Professor at The University of Sydney. He is also a consultant ophthalmologist and Head of Ophthalmology at the Sydney Eye Hospital, as well the medical director of Sydney Retina Clinic and Day Surgery.

In addition, A/Prof. Chang is the secretary general of APVRS and council member of the Asia Pacific Academy of Ophthalmology (APAO). He is also a clinician advisor to the Department of Health Australia and serves on the Board of the Sydney Eye Hospital Foundation. Professional awards he received include APAO Achievement Award and Distinguished Service Award, RANZCO Excellence in Teaching Award and, recently, the APVRS Tano Lecture Award.

A/Prof. Andrew Chang received the Tano Lecture Award from Prof. Chi-Chun Lai, Congress President of 15th APVRS and President of Asia-Pacific Vitreo-retina Society.

The AMD Conundrum

What’s the latest in wet age-related macular degeneration management?

by Tan Sher Lynn

The neovascular form of age-related macular degeneration (nAMD) is one of the leading causes of blindness throughout the world. In the Wet AMD symposium during the 15th Asia-Pacific Vitreo-retina Society (APVRS) Congress, experts discussed recent updates in the management of nAMD, including differentiating its diagnosis from polypoidal choroidal vasculopathy (PCV) on optical coherence tomography (OCT), new treatment regimens and agents, and biosimilars.

Identifying PCV with OCT and fundus exam in the absence of ICGA

Polypoidal choroidal vasculopathy (PCV) is a subtype of nAMD and a variant of type 1 macular neovascularization (MNV), characterized by abnormal choroidal vasculature, including polypoidal lesions and abnormal branching vascular network (BNV) at the edge of the lesion.

“While indocyanine green angiography

(ICGA) is the gold standard to diagnose PCV, when ICGA is not available, we can use non-ICGA diagnostic criteria, such as color fundus photographs (CFP) and OCT as diagnostic tools,” said Dr. Voraporn Chaikitmongkol from Thailand.

He noted that clinical presentations of symptomatic macular PCV can be divided into exudative and hemorrhagic types. On the fundus examination, clinical features suggesting PCV include the presence of subretinal orange nodules (fibrovascular pigment epithelial detachment [PED]), hemorrhagic PED, massive subretinal hemorrhage, peripapillary location, and the absence of large drusen in the fellow eye.

Meanwhile, on the spectral-domain OCT (SD-OCT), the signs of a polypoidal lesion include sharply peaked PED, hyper-reflective ring underneath PED, and notched PED; while the signs of branching vascular network (BVN) are a double layer sign, with some eyes showing pachychoroid and pachyvessels.

In addition to visual acuity, complete polypoidal regression is another treatment goal for PCV. Without ICGA, polypoidal regression can be assessed by OCT features using a three-step grading process — step 1: look for the presence or absence of PED, step 2: look for the internal reflectivity of PED, and step 3: look at the presence of Blended RPE with UNderlying structure (BUN) sign ≥ 2/3 of PED border.

“If you find ‘No PED’n or ‘PED with internal homogenous hyper-reflectivity with predominant BUN sign’, you have 86% accuracy in identifying complete polypoidal regression. And if you find ‘PED with internal heterogenous reflectivity’, you have 85% accuracy in identifying incomplete polypoidal regression,” shared Dr. Chaikitmongkol.

Faricimab: TENAYA and LUCERNE trials

Faricimab is a bispecific antibody that has an inhibitory effect on both VEGF-A and Ang-2 that stabilizes vessels, reduces vascular leakage and inflammation, and inhibits neovascularization.

Dr. Gemmy Cheung from Singapore looked into the TENAYA and LUCERNE trials, which are double-masked, non-

inferiority studies across 271 sites worldwide designed to evaluate patients randomized to receive faricimab 6.0 mg up to every 16 weeks after four initial every-4-week doses, or aflibercept 2.0 mg every 8 weeks after three initial every-4-week doses.

She noted that TENAYA and LUCERNE demonstrated the safety and efficacy of faricimab in nAMD. “At 1 year, primary endpoint was met and about 80% of patients receiving faricimab treatment achieved ≥ Q12W dosing intervals at 48. Reductions in central subfield thickness (CST) with faricimab up to Q16W were comparable with aflibercept at Q8W. Moreover, the effects of faricimab were durable. Vision gains from baseline with faricimab up to Q16W were comparable with aflibercept Q8W through week 112,” she discussed.

“Some clinical experience will be needed to further improve our understanding of where this new therapy will fit in our armamentarium, such as which patients are suitable, what is the dosing regime, disease activity assessment, and criteria,” Dr. Cheung concluded.

Management of PCV with PDT

PCV is an important cause of anti-VEGF sub-optimal or poor response to three loading doses of anti-VEGF therapy, noted Dr. Adrian Koh from Singapore. “Predictors of poor response include thick choroid or pachyvessels, choroidal hyperpermeability, and large or pulsatile polyps,” he shared.

Photodynamic therapy (PDT) is a common treatment for PCV besides antiVEGF therapy. He noted that whether one should choose anti-VEGF monotherapy or combination therapy depends on different reasons.

“Some of the reasons for choosing monotherapy are good initial vision of 6/9 or better, thin choroid, pre-existing RPE atrophy, and when there is massive submacular hemorrhage,” Dr. Koh added.

“Anti-VEGF therapy may be used as firstline treatment. However, if the response is suboptimal or poor, combination therapy with PDT should be considered,” he said, adding that other reasons to choose the combination therapy are a poor baseline VA (<6/9), the presence of

lesions associated with significant but not massive hemorrhage, when there are large or numerous polyps, pulsatile polys, and a large amount of subretinal fluid.

“We have many strategies now to mitigate long-term risk of RPE atrophy, including selective PDT, minimizing spot size, and avoiding repeat full fluency in thin choroid or pre-existing RPE atrophy,” Dr. Koh concluded.

Assessing anti-VEGF biosimilars

Although anti-VEGFs are the first line of treatment for nAMD, they require frequent visits and injections, thereby causing a substantial economic burden to patients.

Biosimilar products are currently being developed to resolve this issue. The availability of biosimilars could reduce the cost of nAMD treatment and expand patients’ access to anti-VEGF treatments, thereby reducing the socioeconomic burden of blindness caused by nAMD.

According to Dr. Neil Bressler from

the US, a 24-week interim results of a 52-week randomized, double-masked, parallel-group, multicenter study were developed to evaluate the safety, pharmacokinetics, and immunogenicity of SB11 compared with ranibizumab (RBZ) in patients with nAMD.

The study demonstrated equivalence between SB11 and RBZ in terms of change from baseline in best corrected visual acuity (BCVA) at week 8, and change in central subfield sickness (CST) at week 4. Other anatomical secondary efficacy endpoints such as the change from baseline in CST, central retinal lesion thickness (CRLT), and choroid neovascularization (CNV) size up to week 24 were comparable between SB22 and RBZ.

“As more biosimilars become available, this is how you should look at the clinical trials. You want to see that other anatomical outcomes match in terms of visual acuity equivalency, you want to be sure that safety, pharmacokinetics, and immunogenicity profiles are similar, and there are at least one-year study results that would provide additional long-term supporting evidence,” Dr. Koh explained.

Speakers (both virtual and physical) had a productive discussion about wet AMD management at APVRS 2022.

What’s in Your VR Toolkit?

A peek into the evolution and advancements of vitrectomy probes

On Day 2 of the 15th Congress of the Asia-Pacific Vitreo-retina Society (APVRS 2022), during a lunch symposium sponsored by Alcon, a panel of vitreoretinal (VR) surgeons convened to discuss advances in techniques and tools in vitreoretinal surgeries.

by Gloria D. Gamat

The session was moderated by A/Prof. Doric Wong (Singapore) and A/Prof. Andrew Chang (Australia), both veterans in the field.

Opening the session was Dr. Sanni Chen from Chinese Taipei, who presented and discussed advancements in cutter technology with her talk entitled ULTRAVIT® 10K and Advanced

Instruments in PDR and Macular Surgery.

A platform for innovation

Dr. Chen, who has been using Alcon’s CONSTELLATION Vision System for more than 15 years, took the audience through the system’s evolution to power every probe — from the 5K to 7.5K cuts per minute (CPM) ULTRAVIT, to the 10K CPM Advanced ULTRAVIT, up to the most recent 20K CPM HYPERVIT Dual Blade Vitrectomy Probe.

According to Dr. Chen, there are unmet needs in the removal of vitreous without any traction on the surrounding retina tissue and in the cutter performance of comparable gauges (27G) to large gauges (23G and 25G).

She emphasized that reducing retina traction and improving procedural efficiency at smaller gauges are key needs and determinants of cutter performance. According to Dr. Chen, the core attributes of cutter performance are cutter shape, cutter speed, and drive technology.

The bevel design, she said, allows the cutter port to be brought into closer proximity to the retina, potentially offering additional control compared to flat tips. On the other hand, higher speeds improve procedural efficiency and reduce the risk of retinal traction.

Furthermore, drive technology (single spring versus dual pneumatic) influences the control of port opening and flow characteristics. All these features, shared Dr. Chen, are on the 10K CPM Advanced ULTRAVIT — the bevel tip design, the high-speed probe which makes it more beneficial for use in highly complex cases — for example, diabetic patients with advanced pathologies, allowing easy access to cutting planes.

A game changer in the field

Just when we thought Advanced ULTRAVIT got it all in terms of a vitrectomy tool, Alcon came up with the HYPERVIT!

HYPERVIT, what A/Prof. Andrew Chang called the “game changer” in this series, was discussed by Dr. Harvey Uy from the Philippines. Dr. Uy, who is involved in the investigation of the HYPERVIT, shared his clinical experiences through his presentation entitled HighSpeed Beveled Cutter: Setting New Performance Standards.

“As VR surgeons, we are facing big challenges in ophthalmology, and we

need all the help we can get,” he shared.

Dr. Uy emphasized that vitrectomy probes are getting smaller and faster and allow VR surgeons to get closer to the retinal tissues. “Once the gauge is smaller, once the cut rate is faster, we can produce better surgeries by decreasing retinal traction during vitrectomy,” he explained.

The latest addition to the Alcon portfolio — the HYPERVIT Dual Blade Vitrectomy Probe — which can go up to 20,000 CPM, features a continuously open port, which is run by a dual-pneumatic drive and features the bevel tip. “I think, right now, this is the best cutter that Alcon has ever produced,” said Dr. Uy.

The benefit of this technology, reported Dr. Uy, is improved fluidic stability. Because of the continuously open port, you don’t have a varying rate of vitreous entry into the cutter.

“We can still remove the vitreous very efficiently and the bevel tip allows a large degree of vertical stability. And all of these is possible because of the dualpneumatic drive which gives us exquisite control of the duty cycle,” he explained.

A new best tool in VR?

“The first thing we noticed in using the HYPERVIT is the reduced peak traction force which translates to decreased pulsatile motion intensity. And looking at the surgical videos presented, you could get very close to the retina and remove even the peripheral vitreous confidently,” shared Dr. Uy.

In addition, the increased vitreous flow sets the HYPERVIT apart from other similar systems, giving VR surgeons a stable way of “vacuuming” the vitreous, as the globe is very stable.

What’s more, the bevel tip provides unparalleled access to the tissue plane, without fear of damaging the retinal tissues underneath, highlighted Dr. Uy. “We can use this very advantageously for removing the membrane on the surface of the retina,” he added.

Both A/Prof. Andrew Chang and Dr. Harvey Uy agree that the HYPERVIT is a great cutter — a much-welcome addition to the VR toolkit, indeed.

(From L-R): A/Prof. Andrew Chang (Australia), Dr. San-ni Chen (Chinese Taipei), Dr. Harvey Uy (Philippines) and A/Prof. Doric Wong (Singapore) – Panel members at the Alcon Lunch Symposium at APVRS 2022

Alcon Lunch Symposium on 19th November at APVRS 2022 Taipei: Path to Precision & Integration in Vitreoretinal Surgeries

Making the Grade

Experts weigh in on bridging the real-world efficacy gap in DME management

by Tan Sher Lynn

pathophysiology involving numerous inflammatory cytokines, chemokine, and vasogenic mediators.

OZURDEX works to help reduce inflammation in the retina and improve visual acuity. Once injected, the implant dissolves slowly and releases a corticosteroid called dexamethasone, which reduces inflammation.

“Corticosteroids have been shown to have anti-inflammatory, antiangiogenic, and blood-retina barrierstabilizing properties, and have different mechanisms of action compared to antiVEGFs,” Prof. Li said.

“RCTs have demonstrated the efficacy and safety of OZURDEX in DME. Meanwhile, real-world evidence (RWE) has shown that suitable naive patients may benefit more in terms of functional outcomes achieved versus previously treated, insufficient responders to antiVEGFs,” he added. “With over 10 years of using OZURDEX in clinical practice, the safety profile of OZURDEX is wellunderstood, and safety outcomes in the real world are consistent with those observed in RCT,” Prof. Li noted.

Individualizing treatment in DME

On Day 2 of the 15th Asia-Pacific Vitreo-retina Society (APVRS) Congress, experts discussed the use of corticosteroid implant OZURDEX® in the management of diabetic macular edema (DME) during a symposium organized by Allergan.

Meeting unmet needs in DME treatment

DME is a leading cause of vision loss and blindness among working-age adults. Diabetes-related and ocular comorbidities can lead to increased burden of care for patients with DME.

This increased burden may then lead to poor adherence to anti-VEGF treatment, which includes a monthly loading phase. Besides, poor adherence to anti-VEGF drugs has been correlated to worse visual

outcomes in real-world clinical practice versus randomized controlled trials (RCTs), noted Dr. Yi-ting Hsieh from Chinese Taipei.

OZURDEX, a tiny corticosteroid implant that slowly releases medication over time, is his treatment of choice in meeting the unmet needs in DME management.

“OZURDEX does not require a monthly loading phase in the first year of treatment, and real-world experience has shown visual acuity gains with OZURDEX,” Dr. Hsieh said.

Reducing inflammation for better vision quality

According to Prof. Xiao-rong Li from China, DME has a complex

According to Prof. Chandra Balaratnasingam from Australia, treatment of DME requires an individualized approach due to its complex pathophysiology and the fact that some patients do not respond sufficiently to anti-VEGF therapy.

“In addition, the burden of treatment may limit clinical outcomes with antiVEGF in the real world versus RCT,” he said, citing the DRAKO study which shows that only 30.2% of patients with DME who received intravitreal aflibercept completed the five loading doses as per label.

“International guidelines and treatment algorithms suggest a number of patient characteristics that can be taken into consideration when deciding treatment for suitable treatment-naive patients with DME. In real-world studies, OZURDEX has demonstrated significant functional improvement in suitable treatment-naive patients that can be maintained for up to five years,” Prof. Balaratnasingam shared.

It Feels So Good! Reunited, and

With Dr. Rajvardhan Azad and friends

With Prof. Gemmy Cheung and friends

With Dr. Harvey Uy and friends

With Dr. Manish Nagpal

With Patrick Foo and Hiroshi LEO Nagatake With Prof. Yang Chung-May

Media MICE CEO Matt Young catches a cloud at the CooperVision booth, promising to fight myopia!