APVRS 2016 - Bangkok, Thailand - DAY 3

APVRSSHOWDAILY December 8-10, 2016

Bangkok, Thailand

The Official Conference News of APVRS 2016

Highlights

5

8

Day

3

Bangkok Today,

Detangling diagnostic

dilemmas in uveitis

Kuala Lumpur Tomorrow!

What’s next in retinal

tumors?

by Gloria D. Gamat

9

T

A few intriguing posters, in case you missed them

Published by:

Editorial Team Creative Content Director

Matt Young

Chief Editor

Gloria D. Gamat Project Manager

Ruchi Mahajan Ranga Writers

John McMahon Kaylen Moore Designer

Winson Chua Photographer

Dwayne Foong

Media MICE Pte. Ltd.

6001 Beach Road, #19-06 Golden Mile Tower, Singapore 199589 Tel: +65 8186 7677 Fax: +65 6298 6316 Email: enquiry@mediamice.com www.mediaMICE.com

he 10th annual congress of the Asia-Pacific Vitreo-retina Society (APVRS 2016) concludes with a resounding bang. With a decade of sharing knowledge and networking with various industry players, this small group of vitreo-retina specialists has grown not just in numbers but also in terms of advances in modalities, procedures and technologies relevant to this ‘rockstar’ ophthalmic subspecialty.

Indeed the innovation has come a long way and it continues to grow as the back of the eye become more and more accessible to surgeons through advancement in tools. Each session in the last three days bore witness to the presentation and discussion of findings from the latest studies on the most challenging of vitreoretinal issues and how to address them.

The festive and chilly weather in Bangkok at this time of the year, with Christmas just around the corner, helped delegates breeze through the halls of Bangkok Convention Center in a joyful mode while reconnecting with friends and colleagues and exchanging clinical pearls. The exhibition hall at APVRS is also getting bolder each year. As innovative equipment and tools become available, exhibiting companies felt the need to showcase their products in a hightech, novel manner as well. Lest we forget, the exhibition booths are indeed becoming better and better each year.

Thank you Bangkok, and thank you to the Royal College of Ophthalmologists of Thailand (RCOPT) for sharing APVRS’s first decade to RCOPT’s 38th annual meeting. Sawasdee Ka. Next year, APVRS 2017 is happening from December 8 to 10 at the Kuala Lumpur Convention Centre, Malaysia, organized with help from the Malaysian Society of Ophthalmology (MSO).

Bye Bangkok, and see you soon Kuala Lumpur!

PhotooftheDay

The Proveo 8 ophthalmic microscope by Leica “goes beyond conventional visualization,” according to the company’s website. Yes, it can even help visualize cool Darth Vader rings….

1

27+ ® portfolio

S ee where smaller can take you

Discover greater access to the smallest of spaces with the new MIVS 27+® portfolio.

®

®

®

®

APVRSSHOWDAILY | December 8-10, 2016 | Bangkok, Thailand

PCV Sufferers Now Live On a Better

Planet Take Away Points from PLANET Study Prof. Gemmy Cheung, MBBS, FRCOphth, senior consultant ophthalmologist, Singapore National Eye Centre, Singapore, noted the following key benefits of Eylea monotherapy: • It achieves significant BCVA gains • It achieves a dry retina in a significant proportion of patients • It achieves polyp regression in a significant proportion of patients • It reduces the need for – and risks associated with – PDT.

By Matt Young

E

arlier this millenium, patients suffering from wet AMD ideally were not losing more lines of vision after treatment.

Now, they are not only gaining doubledigit lines, they are also doing it with far less hassle than ever before.

A new phase IIIb/IV study called PLANET shows Eylea (aflibercept, Bayer) leads to a 10.7 letter gain in visual acuity as monotherapy for sufferers of polypoidal choroidal vasculopathy (PCV), a subgroup of wet AMD. That compares to 10.8 letters in gain with Eylea used in combination with active rescue PDT at 52 weeks, which was not a statistically significant difference. Details on the study were presented at a Bayer press conference at APVRS Bangkok.

“Eylea monotherapy showed similar efficacy to Eylea plus rescue PDT therapy, signifying that Eylea monotherapy can be established as a first line treatment option for patients with visual impairment due to PCV,” said Prof. Won Ki Lee, M.D., Ph.D., Chief of Vitreo-retinal division, Department of Ophthalmology, Soul St. Mary’s Hospital, The Catholic University of Korea.

Further, no active polyps were detectable in 81.7% of patients on Eylea monotherapy, versus 88.9% in the Eylea combined with PDT group. Polyp regression in entirety occurred in 38.9% of monotherapy patients and 44.8% of combined therapy patients, which again was not a statistically significant difference.

This is especially exciting news for AsiaPacific, where PCV occurs more frequently than in Caucasian populations.

“These findings suggest that these patients will be able to benefit from EYLEA monotherapy without requiring the additional time and associated side effects of PDT treatment,” Prof. Lee said.

Prof. Won Ki Lee

The PLANET study appears to be robust, with 333 men and women 50 years or older participating in 62 study sites mainly in the region.

In context, these study results also are compelling.

In a study called EVEREST II, Lucentis (ranibizumab, Novartis) led to a 5.1 line gain in visual acuity at 12 months, versus an 8.3 line gain when combined with PDT. While PLANET is clearly a different study, notably Eylea led to a doubledigit line gain even as monotherapy, and demonstrated enough evidence to not require PDT for better performance.

Prof. Gemmy Cheung

3

4

APVRSSHOWDAILY | December 8-10, 2016 | Bangkok, Thailand

New Frontiers in Vitreoretinal Diseases: Artificial Vision, Stem Cells and Gene Therapy Talking about the cutting edge trial for ocular gene therapy, Dr. Suber Huang, M.D., MBA, Retina Center of Ohio, presented strategies for the future of gene therapy. His was the first randomized controlled phase 3 therapy trial for a genetic disease in the United States.

The study showed highly statistically significant improvements in the primary and first two end points. Phase 1 cohorts generally maintained improvement for at least three years. Subjects will continue to be followed for 15 years for evaluation.

He concluded by saying that gene therapy continues to hold promise for the treatment of inherited retinal disease.

by John McMahon

T

his panel discussion, co-chaired by Dr. R.V. Paul Chan, Dr. Taraprasad Das and Dr. Warapat Wongsawad, revolved around discussion of a number of treatment options for patients with retinal degenerative disease. Speakers addressed either biological methods (i.e. gene therapy, stem cell therapy) or electromechanical methods (i.e. retinal prosthesis). A specific gene is delivered via viral vector in gene therapy. The entire cells are infused or transplanted into a patient in stem cell therapy. Visually useful percepts are created by stimulating the retinal ganglion cells in retinal prosthesis.

The panel deliberated on these new frontiers in vision restoration modalities.

Dr. Das began the discussion with an overview on sight restoration boundaries.

He began with a summation of sub-retinal injections of fetal neural retina and spoke on the current and future states of stem cell therapy before speculating briefly on the future of biomechanics in retinal repair.

Dr. Masayo Takahashi, M.D., PhD, presented the first application of retinal Therapy, her first application of induced pluripotent stem cells (IPS) for transplant. She demonstrated the process of elevating the function of new cells resulting in the selection of RPE cells as the safest cell type. Her first case transplant followed post-surgery over two years resulted in the survival of cellular tissue and improved visual acuity for her patient. Having started a new clinical trial in June of 2016 she and her team look forward to further developments.

Dr. Ian Constable

The topic of gene therapy was addressed again by Dr. Ian Constable’s panel presentation on gene therapy and vision restoration. He compared wild type adeno-associated virus vectors (AAV) and AAV for gene therapy in large organs before turning to the different needs of the eye. He bullet pointed the needs for precise injections, optical monitoring, the blood retinal barrier and active RPE cells for protein production. He concluded that modified gene therapy may prove to be an alternative to conventional injections for patients with age-related macular degeneration (AMD).

Dr. J. Fernando Arevalo, M.D., FACS, The Wilmer Eye Institute-Johns Hopkins University School of Medicine, Baltimore, brought the current status of Argus II Retinal Prosthesis to the board. The prothesis, also known as the bionic eye sends messages from a video camera in the patients’ glasses to a patient worn computer where they are transmitted via antenna to a retinal implant in the form of impulse. These impulses are then transferred to the patients’ brain as patterns of light which the patient learns to interpret over time. The effectiveness of the device is as yet clinically established but early studies promise results.

Dr. Calvin Pang, BSc (Lond), DPhil (Oxon), Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, was supposed to discuss ocular stem cells and retinal disease but left the panel early for an emergency in Hong Kong. Hence his presentation was delivered by his colleague, Dr. Michael Te Ng. Dr. Te walked the panel through the future developments of stem cell therapies. First he outlined that embryonic, fetal and umbilical cord tissue-derived stem cells and bone marrow-derived stem cells have and are used to treat visual disorders. He used sides to show a decade of analyzing the developmental clues involved in retinal generation and stem cell biology, coupled with extensive surgical research which have yielded differing cellular approaches to tackle these retinopathies. He ended by discussing the challenges of stem cell therapies in the future. The panel came to an end after an enthusiastic question and answer period.

Dr. Suber Huang

APVRSSHOWDAILY | December 8-10, 2016 | Bangkok, Thailand

Diagnostic Dilemmas in Uveitis diagnosis of the masquerade, significant morbidity and mortality can be averted.

by Kaylen Moore

W

ith standing room only, this seminar was popular among conference attendees looking to learn more about the challenges faced with uveitis diagnosis, as well as new methods and indicators for disease determination.

Dr. Pitipol Choopong, M. D., began the session with a discussion on anterior uveitis, and how it can present as noninfectious, infectious, or masquerade. To help solve the puzzle, he suggests three items: history taking, clinical evaluation and investigation. He also began what would become a theme, stating strongly that selective investigations should be performed to confirm the diagnosis, especially in clinical cases.

Following Dr. Choopong, Professor Lyndell Lim, MBSS, FRANZCO, Senior Associate Ophthalmologist, Eye Surgery Associates, Melbourne, Australia, presented tips on managing acute presentations of posterior/panuveitis. Prof. Lim stressed the need for critical evaluation of the indicators, and says her key questions are “Am I dealing with a faker? Is this an infection? Is this masquerade?”

The most important investigation of uveitis is a thorough history and examination, to look at the eyes as a part of the whole patient to get correct diagnosis. She noted that it is not anterior uveitis until the possibility of posterior uveitis with fully dilated posterior has been excluded.

She stressed the importance of careful use of long acting steroids when the diagnosis is still in flux, and recommends using oral steroids instead as the first line of antiinflammatory to use since they are easier to stop abruptly (<7 days).

Presenting on ‘Viral Retinitis—The Challenges’, Dr. Hazlita Mohd. Isa, M.D., University Kebangsaan, Malaysia, began by reminding the audience, “Despite advancement in diagnostic tools and treatment modalities in ophthalmology viral infection in the eye remains difficult to diagnose and treat.” The four challenges experienced are: identifying the exact causative virus, differentiating the various types of viral retinitis, symptoms are unreliable leading to diagnostic delay, other conditions which mimic the same signs and symptom clinically.

There are many viruses known to cause retinitis including herpes simplex, flaviviruses, and HIV. In relation, patient immune status can play a large role in identifying the type of viral retinitis, for example in herpetic retinitis, acute retinal necrosis (ARN) is more common in immunocompetent patients, while cytomegalovirus retinitis (CMV) and progressive outer retinal necrosis (PORN) are more common for immunocompromised patients.

Diagnostic tools play a role in atypical presentation of viral retinitis, but all physicians should have a high level of suspicion for infection with atypical presentations. Acting early is crucial to prevent severe complications and irreversible vision loss.

Masquerade disease was the focus for Dr. Nor Fariza Ngah, M.D., Medical Retina & Uveitis Services Ophthalmology, Shah Alam, Malaysia. This group of disorders which mimics ocular inflammatory diseases can be difficult to identify, and deserves wide attention as these are not only vision threats, but also can be fatal to patients.

However, with early recognition and

Understandably, diagnosis and evaluation of masquerade disorders are often comanaged with other specialties such as oncology. This teamwork is crucial, but sometimes slow as she reported an average of 21 months from patient presentation to diagnosis for such cases.

She urged all of the ophthalmology community and beyond to work together to overcome the challenges of diagnosis and treatment of masquerade disorders.

With surgical videos that had the audience engaged and on the edge of their seats, Dr. Ekta Rishi, M.S., Sri Bhagwan Mahavir Vitreoretinal Services, Chennai, India, showed surgical management of eyes with uveitis. She agreed with previous presenters, and concluded that all care providers need to work together to rule out any recurrent inflammation as a key to successful surgery.

Closing out the session with metastatic endophthalmitis was Dr. Taiwan Shwu-Jiun Sheu, M.D., Kaohsiung Veterans General Hospital, National Yang Ming University, Taiwan). Metastatic endophthalmitis, emphasized Dr. Sheu, is typically the result of hematogenous spread, but without any age/sex predilection, and typically occurring in the right eye, and in immunocompromised patients. She noted that in India, 7% are endogenous, while the endogenous rate is 41% in Britain, and 26% at her own hospital in Taipei.

Once again the importance of treating not just the eye, but the whole patient was raised. Dr. Sheu stressed, “Beware of treating only the eye, and losing the life.”, Also both diabetes and Asian ethnicity are high risk factors. Early vitrectomy is now the trend for treatment.

The session concluded with a few questions, where Prof. Lim once again advocated for strong departmental teamwork and encouraged all attendees to “be at the table” to ensure the best comprehensive care for their patients, for which she received a hearty applause.

5

6

APVRSSHOWDAILY | December 8-10, 2016 | Bangkok, Thailand Spotlight on Key Symposium

Intravitreal Sirolimus A

ny part of the eye can be affected by uveitis, which can be infectious or noninfectious. In non-infectious uveitis (NIU), the pathophysiology is often of autoimmune origin, manifesting secondary to systemic diseases or due to local conditions.

Inflammation of the uvea and adjacent structures in NIU is mediated by T cells and perpetuated by proinflammatory cytokines.

Therefore, treatments for NIU target the inflammatory pathology. This includes systemic and local corticosteroids, systemic immunosuppressants and biologics.

Although systemic corticosteroids are effective in a majority of patients, its longterm use is associated with a risk of serious adverse effects.

New therapy on the horizon…

What if NIU can be treated by a localized immunoregulator? In that case, serious adverse effects associated with the use of systemic immunosuppressants would not be an issue.

Enter intravitreal sirolimus – a local immunoregulatory therapy for managing non-infectious uveitis of the posterior segment (NIU-PS). This novel agent is an mTOR inhibitor that plays immunoregulatory role by interrupting T-cell proliferation driven by interleukin-2 (IL-2) and other proinflammatory cytokines, with minimal systemic exposure.

Promising Novel Localized Immunoregulatory Therapy for Non-Infectious Uveitis of the Posterior Segment

SAKURA Study 1 is the first of two Phase III, randomized, double-masked, multinational studies conducted in the European Union, India, Israel, Japan, Latin America, and the United States, evaluating the long-term safety and efficacy of intravitreal sirolimus. The study’s primary objective is to evaluate the safety and efficacy of the intravitreal injection of 440 μg and 880 μg sirolimus versus 44 μg for the treatment of active NIU-PS. As part of the SAKURA Study 1, Dr. Alay S. Banker, M.D., from Banker’s Retina Clinic and Laser Centre, Ahmedabad, India, and his team examined the 12-month safety outcomes of intravitreal sirolimus in Indian subjects with active NIU-PS. Study findings demonstrated that overall, a significantly higher proportion of Indian subjects receiving the 440 μg dose (31.4%) of intravitreal sirolimus injections for NIU-PS achieved a resolution of inflammation (VH of 0) when compared to those who received the active control dose of 44 μg (10%).

The investigators highlighted that although ocular adverse events (AEs) and serious AEs observed with intravitreal injections of sirolimus in SAKURA Study 1 were not unexpected, the incidence rate of ocular serious AEs did not increase with long-term use.

“The 440 μg intravitreal sirolimus injections may be an efficacious and safe therapeutic option for non-infectious uveitis of the posterior segment,” shared Dr. Banker. “Also, the SAKURA Study 2 may provide additional data on the

Details of the SAKURA Study 1 findings will be presented at the APVRS Congress 2016 on December 10, 2016 (Saturday), 14:30 – 16:00 hrs, at Lotus 11.

The findings are based on research by the following physicians (and please note their presentation titles as well):

Dr. Alay S. Banker

Dr. Vishali Gupta

Intravitreal Sirolimus: Long-Term Safety Results in Indian Subjects with Noninfectious Uveitis of the Posterior Segment

24-Month Safety Outcomes: Treatment of Noninfectious Uveitis of the Posterior Segment with Intravitreal Sirolimus

For more information, please contact: Dr Femmy Yunia Bahroen at femmy.bahroen@santen.asia This symposium preview has been supported by an educational grant from Santen.

References: Mudumba S, Bezwada P, Takanaga H, et al. Tolerability and pharmacokinetics of intravitreal sirolimus. J Ocul Pharmacol Ther. 2012;28(5):507-514.

Nguyen QD, Merrill PT, Clark WL, Banker AS, et al.; Sirolimus study Assessing double-masKed Uveitis tReAtment (SAKURA) Study Group. Intravitreal Sirolimus for Noninfectious Uveitis: A Phase III Sirolimus Study Assessing DoublemasKed Uveitis TReAtment (SAKURA). Ophthalmology. 2016;123(11):2413-2423.

benefit/risk profile of intravitreal sirolimus for the treatment of NIU-PS,” he added.

In a similar study, Dr. Vishali Gupta, M.D., from Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India, and her team evaluated the 24-month safety outcomes of intravitreal sirolimus for the treatment of active NIU-PS. The investigators found that the most efficacious dose of 440µg was observed to be safe and tolerable over the 24-month study period. More importantly, the systemic exposure to sirolimus fell below the immunoregulation threshold and no clinically relevant systemic safety issues were reported in subject patients.

“A major issue in NIU is that it keeps coming back. To prevent recurrences, a form of immunoregulator therapy needs to be administered,” said Dr. Gupta.

“But the problem with treatment is that it comes with a lot of systemic side effects. In NIU-PS, the disease is local in the eye, and a local immunoregulator is the ideal treatment scenario,” she explained.

“Uveitis is a potentially blinding disease, and we don’t have a better alternative to systemic immunoregulator at the moment. Intravitreal sirolimus will allow treatment of the condition in a localized manner (without the systemic side effects) and I’m so looking forward to it,” she concluded.

APVRSSHOWDAILY | December 8-10, 2016 | Bangkok, Thailand

Optimizing Vitreoretinal Surgery with the Latest Technologies and a Revolutionary Visualization Process

“hasIt [Constellation] totally changed the way of surgery, the way we see the world, and how we work together as a team.

by Kaylen Moore

T

- Dr. Nuttawut Rodanant

he Alcon sponsored lunch symposium kicked off with a bang, with Dr. Nuttawut Rodanant, Associate Professor, Mahidol University, Siriraj Hospital, Bangkok, Thailand, presenting the Constellation Vision System.

from wide angle illumination to multiple different forceps and scissors. It is a great platform, as we have multiple surgeons at our institution and you can appease all of them based on their own unique needs,” Dr. Ehlers noted.

“Why Constellation? It’s the ‘wow’ factor!” said Dr. Rodanant. “It’s already been in the market for more than 8 years, and has continued to improve. And actually even more ‘wow’ than Constellation, is its new platform,” he explained. He was particularly impressed with the real-time infusion adjustments, and the technology’s ability to enable constant globe stability, plus the user-friendly interface.

“In Constellation I think, the biggest change for us was the ability to use the small gauge to its full extent,” said the session’s moderator, Dr. Manish Nagpal, M.D., from Ahmedabad, India.

Dr. Young Hee Yoon, M.D., University of Ulsan College of Medicine, Seoul, South Korea, has only used the MIVS 27+ portfolio for five cases thus far, but has seen a lot of opportunity for her patients’ future. “At the beginning I thought that it would probably be for more simple cases because it is a smaller gauge, but in fact I was convinced that it’s even better for more complicated cases because it is smaller and less traumatic,” she said.

“We used to feel as though we weren’t getting the feel of the movement [with larger gauges], which changed totally when Constellation came” emphasized Dr. Nagpal. Closing out the session, the panel concluded that they look forward to more exciting advances from Alcon and this technology in the future.

If I have a 27+ “gauge available

in Korea, I would probably switch most cases to 27+ gauge.”

- Dr. Young Hee Yoon

“

From an operating room perspective, it [NGENUITY 3D Visualization System] also improves surgery ergonomics and is a platform created to foster strong collaboration.

”

- Dr. Justis Ehlers

In [Constellation] “I think, the biggest

The final presenter of the session, Dr. Justis Ehlers, M.D., Cole Eye Institute, Cleveland, Ohio, USA, introduced the NGENUITY 3D Visualization System, which offers numerous advancements for enhanced depth of field, magnification via high definition cameras, a 4K screen, color filters, and much more.

“Now with 27+, we’ve got multiple gauge systems we can use and everything

”

change for us was the ability to use the small gauge to its full extent.

- Dr. Manish Nagpal

NGENUITY 3D Visualization System demo at Alcon booth

”

7

8

APVRSSHOWDAILY | December 8-10, 2016 | Bangkok, Thailand

Another familiar face from the day before, Dr. Duangnate Rojanaporn, M.D., Rutnin Eye Hospital, Thailand, presented the current treatments of intraocular retinoblastoma. Beginning with the pro's and con's of systemic chemotherapy treatment on retinoblastoma, she went on to explain the techniques used presently in Thailand. Moving to intra-arterial chemotherapy with a series of slides demonstrating primary and secondary treatments she has used with minimal side effects.

by John McMahon

I

n this panel session, a variety of leaders in the field from the Asia Pacific region and abroad provided a summary of current standards for retinal tumors.

It emphasized on the treatment of intraocular and extraocular disease as well as on the various types of chemotherapy that can be employed.

Opening the panel discussion with a talk on diagnosis of vitreoretinal lymphoma, Dr. Hiroshi Goto, M.D., Department of Ophthalmology, Tokyo Medical University, Japan, re-capped diagnosis from fluid and tissue samples and listed the steps that make a sample suspect. He emphasized the importance of clinical observation and concluded with a chart of subretinal and atypical types of lymphoma.

Discussing multimodal imaging of retina, Dr. Minoru Futura, M.D., Fukushima Medical University, Japan, showed slide examples of lymphoma with ultra wide field imaging. He followed with a demonstration of adaptive optics which enables visualization of the living cone photoreceptor. He also covered angiography devices and discussed the various benefits of each method.

He finished his lecture by listing noninvasiveness, speed and objectivity as the three criteria when making a diagnosis by multimodal imaging.

Dr. La-ongsri Atcheneeyasakul, M.D., Thailand, introduced a subject that would be the focus for the remainder of the program: retinoblastoma. She started her presentation with a quote from John Diamond, 'cancer is a word, not a sentence', which garnered nods of appreciation from the panel as a whole.

She continued to make a very thorough discussion of the different systems of classification before settling on the international A-E system as both the simplest and best of three discussed.

The esteemed Dr. Jerry Shields M.D., Wills Eye Hospital, Philadelphia, took the dais to applause from an appreciative panel.

He discussed lesions that can simulate retinoblastoma, demonstrating the difficulty of correct diagnosis between retinoblastoma and several other conditions that can appear similar in layers of the eye. Dr. Shields challenged the audience to compare a series of slides showing retina with similar visual conditions to make the correct diagnosis.

Later on, Dr. Vikas Khetan, M.D., Associate Consultant, Sankara Nethralaya, India, took over to talk about the genetics of retinoblastoma â&#x20AC;&#x201C; a look at heritable versus non-heritable forms of retinoblastoma. He charted both types with genetic trees which showed the different disease pathways. He ended with an overview of the genetic predisposition of retinoblastoma and the two differing international systems to classify them.

The panel's co-chair, Dr. Carol Shields, M.D., Wills Eye Hospital, Philadelphia, introduced giant leaps in retinoblastoma treatment â&#x20AC;&#x201C; a look at the management over the last 10 years and what the future will bring. Abstracting the years of knowledge and experience, what Dr. Shields brings to a lecture is near impossible as she broke down the progress in chemotherapy and weighed the benefits of the three major classification systems in a seamless and entertaining way before ending with a look at the toxicity of chemotherapy and its serious side effects. She followed her talk with the most active question and answer session of the panel.

Ending the session, Dr. Chanet Suvarnamani, M.D., Samitivej Hospital, Bangkok, Thailand, discussed the evolution of retinoblastoma care beginning with enucleation, early radiation therapy, intra-arterial chemotherapy to the present intravitreal chemotherapy. He shared several case studies of patients of widely different age groups and their reactions to treatment.

APVRSSHOWDAILY | December 8-10, 2016 | Bangkok, Thailand

Poster Alley

by Matt Young

Not to be outdone by RANZCO (see APVRS Show Daily Day 1), APVRS itself has some intriguing scientific posters in the exhibition hall. Let’s have a look….

Implant to Overcome Hypotony Ozurdex (Allergan) is indicated for use in branch/central retinal vein occlusion, diabetic macular edema and noninfectious posterior segment uveitis – but another clinical application may have emerged: hypotony management.

A series of case studies involving a 42-year old man, 72-year-old man, and 29-year-old woman each had hypotony for various reasons. The 42-year-old had chronic uveitis complicated by secondary glaucoma in the left eye. He had Ahmed glaucoma valve implantation and developed hypotony. The 72-year-od also had Ahmed glaucoma valve implantation and hypotony. The woman had PPV with scleral encircling in her right eye due to recurrent retinal detachment with proliferative vitreoretinopathy.

For these patients, intravitreal implantation of Ozurdex occurred on average 3.67 times.

The mean IOP increased from 5.91 +/- 1.92 mm Hg to 12.36 +/- 3.17 mm Hg after Ozurdex implantation (P =0.03).

Limited improvements in visual acuity were noted, but subjective comfort improved with IOP elevation. Interestingly, the most frequent observed adverse effect of Ozurdex is IOP elevation, but here, it was of some help.

“It seems to be effective in ocular hypotony related to chronic intraocular inflammation,” reported lead poster author Dr. Have Jung Sun, Department of Ophthalmology, Soonchunhyang University College of Medicine, Soonchunhyang University Hospital, Seoul, Korea.

Choroidal Nevus, Uncovered

Cat Scratch Fever...and Macular Hole!

Understanding of choroidal nevus is limited in Asian populations – at least until now.

Research supported

by Duke-NUS Medical School, Singapore National Eye Centre (SNEC), and the Singapore Eye Research Institute (SERI) has advanced further understanding about this common intraocular tumor.

While the tumor typically is benign, it has been tied to uveal melanoma risk. Further, when located in the subfoveal region, it could impact vision.

“Choroidal nevus is not uncommon among Asians,” reported lead poster author Dr. Ning Cheung, of Duke-NUS, SNEC, and SERI. “It is more frequently found in younger persons and less frequently seen in females. There was no significant ethnic difference among the Asian populations examined in this study.”

The researchers found that 37.6% of study participants had more than one choroidal nevus, and 1.7% had bilateral choroidal nevi. Choroidal nevus findings were similar across three ethnic populations: Chinese, Malay and Indians.

In what is reported to be only the second macular hole caused by B. henselae, a 12-yearold girl with a history of keeping pet cats also had a history of left visual loss.

She had swelling of the optic disc and a macular hole in the left eye.

“We performed a vitrectomy at 60 days from the first medical examination,” reported lead poster author Dr. Shun Kumashiro, of Toho University, Tokyo, Japan. “To the best of our knowledge, there has been no previously reported case of vitrectomy resulting in a closed macular hole.”

However, researchers did successfully close this macular hole.

“After inflammation was decreased by oral prednisolone, we used the inverted ILM flap technique to achieve successful anatomical and functional outcomes in a patient with a fullthickness macular hole in CSD,” Dr. Kumashiro noted.

9

10

APVRSSHOWDAILY | December 8-10, 2016 | Bangkok, Thailand

A Brief Summary of

APVRS 2016 Ian Constable and RCOPT Rutnin Lectures his award it was clear of his respect for Dr. Rutnin’s legacy, and shared that his own mother trained with him during her residency.

by Kaylen Moore

T

he Ian Constable and Rutnin lectures are each awarded to distinguished participants who are exemplary in their respective fields, and also show a contagious passion for retinal ophthalmology.

Firstly, Professor Ian Constable is the founder and current professor at the Lions Eye Institute (Perth), where their mission is to achieve leadership in scientific research and clinical practice in the prevention of blindness and eye diseases.

An innovator, accomplished academician, and outstanding vitreoretinal surgeon, Prof. Constable is also a pioneering expert in gene therapy and retinal disease, who greatly respects young, emerging scientists. During his introduction he expressed confidence that the best future technology, inventions and translations will come from these scientists and the Asia Pacific region.

This year’s recipient was Dr. Jay Chhablani, M.D., L.V. Prasad Eye Institute, Hyderabad, India, an outstanding clinician-scientist who has recently focused on the imaging of the retina and macular diseases.

His presented lecture, intravitreal zivaflibercept: clinical effect and economic impact came from several of his papers on this subject, out of his 170+ published in peer reviewed journals.

He began by reviewing current first-line anti-VEGF (anti-vascular endothelial growth factor) agents for wet AMD

(age-related macular degeneration) in use today, with aflibercept at about 21%. Osmolarity differs for aflibercept (300mOsm/Kg) and ziv-aflibercept (1000 mOsm/Kg), and noted that more than 500 mOsm/Kg causes retinal pigment epithelium (RPE) damage in rabbits and primates.

After extensive research, Dr. Chhablani reports success in managing injection levels with ziv-aflibercept with no clinical toxicity. This can be used to treat AMD, diabetic macular edema, polypoidal choroidal vasculopathy (PCV), non-AMD choroidal neovascular membrane (CNVM) and with less injections than other options, at a far lower cost.

For example, treatment of diabetic macular edema could drop by 98% down to $300 annually/person with ziv-aflibercept and other conditions see similar savings as well. But currently, the medication is difficult to obtain in many parts of the world. Dr. Chhablani concluded that off-label use of intravitreal ziv-aflibercept is safe and effective, and easy access to it is imperative worldwide.

The Rutnin lecture, named in honor of Dr. Uthai Rutnin, was awarded this year Dr. R V Paul Chan, M.D., llinois Eye and Ear Infirmary, University of Illinois at Chicago, Illinois. Dr. Rutnin is known as the father of Thai retina specialists, in addition to being a pioneer for ophthalmology in Thailand.

When Dr. Chan took the stage to receive

Dr. Chan presented the evolving management paradigm for pediatric retina and retinopathy of prematurity, with focus on imaging and FA (fluorescein angiography). He noted that when using FA to determine if a color fundus image of was one of five diseases, almost half of study participants altered their choice of category. Further, after viewing the corresponding FA to each set of the same images, participants altered their choice of management by about 25%. He stated that this means we are potentially getting the right answer more often for clinically significant diseases.

FA can be useful in pediatric management of Coat’s disease, (familial exudative vitreoretinopathy) FEVR, incontinentia pigmenti, tumors, and more. It can also improve quality of care through telemedicine by being cost-effective, accurate, and reliable. This type of breakthrough can play a big role in the future of increasing access to care for children worldwide.

After his lecture, Dr. Chan said, “For me this award was a tremendous surprise and I am so happy to be a part of this congress, which the whole Thai retina community was really excited about. It is amazing for me to see the openness and progressiveness of Thai ophthalmology, and it is truly an international community.

Everybody is so focused on training and elevating the next generation of people, and I feel privileged to be a part of that.”

APVRSSHOWDAILY | December 8-10, 2016 | Bangkok, Thailand

Aflibercept, Setting a New Standard in

nAMD and PCV Treatment Talking about the long-term efficacy of anti-VEGFs with treat-and-extend regimen (findings from ATLAS Study), Dr. Carl Regillo, Wills Eye Hospital, Philadelphia, USA, explained the two phases of nAMD treatment (induction and maintenance) and the three categories of anti-VEGF treatment regimens (continuous fixed, discontinuous variable and continuous variable a.k.a. treat-and-extend). Also, Dr. Regillo noted that in real life, VA gains can be difficult to maintain in the long term and that treat-and-extend is a practical, proactive treatment regimen.

by Gloria D. Gamat

P

olypoidal choroidal vasculopathy (PCV), a subtype of neovascular age-related macular degeneration (nAMD), took center stage at the Bayer lunch symposium as the audience was introduced to the discussion on key trials in PCV, including results from the PLANET and ATLAS studies and other long term studies on the use of aflibercept in the treatment of PCV. Characterized by abnormal choroidal vascular networks ending in polyps, PCV is considered a variant of type 1 choroidal neovascularization (CNV). While it affects people of all ethnicities, the condition is more prevalent in the Asian community.

Prof. Gemmy Cheung, MBBS(Lond), FRCOphth(UK), Senior Consultant, Singapore National Eye Centre, highlighted concerns surrounding treatment of CNV with PDT (photodynamic therapy) in terms of safety, efficacy and cost. During the lecture, she also explored the practical considerations of aflibercept monotherapy versus alternative treatment options for PCV and emphasized that the long term outcomes of PDT in PCV still remain a concern.

The gold standard for PCV diagnosis is indocyanine green angiography (ICGA).

This procedure reveals characteristic polyph-like hyperfluorescent lesions arising from the choroidal vasculature.

VEGF is elevated in PCV, although to a lesser extent compared to a typical AMD. Data from the VIEW 2 and VAULT studies suggest that aflibercept monotherapy is effective for the treatment of PCV. Findings showed that treatment with aflibercept monotherapy achieves significant BCVA gains, achieves polyp regression in a substantial proportion of patients and reduced the need for, and risks associated with PDT. “Anti-VEGF agents are now the standard of care for nAMD. Since PCV is a common subtype of nAMD and a variant of type 1 CNV, it just makes sense that aflibercept shows favorable outcomes in PCV patients,” concluded Prof. Cheung.

The efficacy of aflibercept alone and in combination with rescue PDT was investigated in the PLANET study.

Presenting key findings from this study, Professor Won Ki Lee, Seoul St. Mary’s Hospital, Catholic University, South Korea, highlighted that aflibercept monotherapy leads to favorable vision gains (gain of over 10 letters from baseline), high rates of polyp inactivation at week 52 ( over 80% of patients showed no evidence of active polyps) and over 85% of patients needed no rescue PDT treatment. During the 52 week-period, patients received a mean of 8 injections of aflibercept and the adverse events reported were consistent with the drug’s established safety profile.

In the treat-and-extend concept, treatment is initiated until disease is stable and then gradually extend time between treatments until fluid recurs or VA declines,” explained Dr. Regillo. “It has the potential to minimize recurrences or setbacks [compared to other regimens] and reduces the risk of over-treatment,” he added. Furthermore, Dr. Regillo emphasized that aflibercept is well suited to a treat-and-extend regimen, as it was specifically designed for a strong, broad and sustained activity.

Last but not least, Dr. Shi-Jen Chen, M.D., Taipei Veterans General Hospital, Taipei, Taiwan, talked about the comparison between monotherapy and combination therapy in PCV from a clinician’s perspective. He emphasized that the results of EVEREST II and PLANET studies may answer unaddressed question in PCV treatment. More importantly, key findings demonstrated that aflibercept-PDT combination therapy is not required for patients to achieve substantial visual and anatomic gains.

The panel had an engaging and lively discussion with the audience and they agreed that the new data presented is more than enough to make the vitreoretinal community excited about the potential of aflibercept in PCV treatment.

The session closed with a take home message that the second year of PLANET study will assess the efficacy of aflibercept treat-and-extend in PCV, and that Bayer is committed to expanding the evidence base in this subject matter.

11

Abbreviation of Eylea Product Information: Presentation; 1 ml. solution for intravitreal injection contains 40 mg aflibercept Indication: for treatment of neovascular (wet) age-related macular degeneration (wet AMD), macular edema secondary to central retinal vein occlusion (CRVO), diabetic macular edema (DME), macular edema secondary to branch retinal vein occlusion (BRVO), myopic choroidal neovascularization (myopic CNV). Dosage and method of administration: For Neovascular (wet) age-related macular degeneration (wet AMD), the recommended dose for Eylea is 2 mg (equivalent to 50 microliters) intravitreal injection. EYLEA treatment is initiated with one injection per month for three consecutive doses, followed by one injection every 2 months. For Macular edema secondary to central retinal vein occlusion (CRVO), the recommended dose for EYLEA is 2 mg. After the initial injection, treatment is given monthly until visual and anatomic outcomes are stable for three monthly assessments. For Diabetic macular edema (DME), the recommended dose for EYLEA is 2 mg administered by intravitreal injection monthly for the first 5 consecutive doses, followed by one injection every 2 months. Macular edema secondary to branch retinal vein occlusion (BRVO), the recommended dose for Eylea is 2 mg. After the initial injection, treatment is given monthly. For Myopic choroidal neovascularization (myopic CNV), the recommended dose for EYLEA is a single intravitreal injection of 2 mg. Additional doses should be administered only if visual and anatomic outcomes indicate that the disease persists. Contraindications: Ocular or periocular infection, Active severe intraocular inflammation, Known hypersensitivity to aflibercept or to any of the excipients. Special warnings and precautions for use; Intravitreal injections including those with EYLEA, have been associated with endophthalmitis, Increase in intraocular pressurehave been seen within 60 minutes of an intravitreal injection, Women of childbearing potential should use effective contraception during treatment. Adverse reactions: Very common (≥1/10 patients) Conjunctival hemorrhage, Eye pain Selected adverse reactions: Arterial thromboembolic events (ATEs) are adverse events potentially related to systemic VEGF inhibition. There is a theoretical risk of ATEs following intravitreal use of VEGF inhibitors. Immunogenicity-as with all therapeutic proteins, there is a potential for immunogenicity with EYLEA. Incompatibilities: EYLEA must not be mixed with other medicinal products

โปรดอานรายละเอียดเพิ่มเติมในเอกสารกำกับยา ใบอนุญาตโฆษณาเลขที่ ฆศ. 726/2559