A supplement to PIE Magazine 09 www.piemagazine.org
SPECIAL REPORT The Retina
Subspecialty Takes Center Stage at
by Brooke Herron
APAO Bangkok
Despite the retina subspecialty being just one of the many ophthalmic specialties being presented at the Asia-Pacific Academy of Ophthalmology Congress (APAO 2019) in Bangkok, Thailand, the topics – from medical to surgical retina, in e-posters alone – deserve a special spotlight. Here are some that delegates are going to look forward to…
“supplemental unmonitored oxygen for prolonged duration and multiple systemic co-morbidities could be a contributing factor.”
Risky business: Contributing factors in AP-ROP
In recurrent central serous chorioretinopathy (CSCR), choroidal neovascularization (CNV) can occur as a result of persistent or recurrent serous macular detachment. Therefore, in an e-poster called Atypical Choroidal Neovascularization Presenting in Recurrent Central Serous Chorioretinopathy, Drs. Vega Casalita and Ari Djatikusumo aim to demonstrate that CNV can be managed as a complication of chronic, persistent CSCR.
Retinopathy of prematurity (ROP) is a leading cause of childhood blindness. In its more severe (and rare) state – aggressive posterior retinopathy of prematurity (AP-ROP) – the condition rapidly progresses, often causing impairment, despite appropriate and timely treatment. To take a deeper look into the disease’s pathogenesis, Dr. Srijita Mitra and colleagues presented an e-poster called A Retrospective Analysis on the Risk Factors for Aggressive PosteriorRetinopathy of Prematurity. In this observational case series, the authors examined patient files for 30 babies. Parameters including birth weight, gestational age, post conceptual age, associated illness, duration of oxygen supplementation and treatment advised, were analyzed. The authors found that all 30 babies received supplemental oxygen for three days (or more) after birth and all had other systemic comorbidities. The mean gestational age was 30.3 weeks and mean birth weight was 1.27 KGs. Forty-eight eyes of the 30 patients showed AP-ROP on examination, of which 29 eyes
(60.4%) had zone II posterior AP-ROP, and 19 eyes (39.6%) had zone I APROP. Of the 30, 22 babies received laser and intravitreal anti-VEGF treatment. These results led the authors to conclude that “in our case series, AP-ROP in premature infants occurs mostly in posterior zone II, with flat neovascularization and atypical features like large vascular loops.” In addition, they found that
Stop CNV in its tracks.
The domino effect: Treat CNV as a complication of CSCR
POSTERIOR SEGMENT The authors detail the case of a 53-year-old woman, who complained of a six-month history of decreased object sharpness and color sensitivity in the central field area of her left eye. After examination, visual acuity (VA) was 20/40 and clinical examination showed wellcircumscribed submacular fluid, with multiple small yellow deposits (as confirmed by OCT). In addition, fluorescein angiography (FA) revealed pinpoint hyperfluorescence outside the fovea avascular zone, followed by dye leakage throughout the phase at superior macular region. According to the case report, the patient underwent focal laser photocoagulation treatment. Three months following treatment the disease showed complete resolution. The patient was followed-up six months after laser treatment. It was found that her VA had decreased to 20/150, and there was a presence of subretinal fluid, accompanied by a pigment epithelial detachment and irregular RPE appearance on OCT. Using FA, the patient showed late phase hyperfluorescence in inferior macula region – which is suggestive of CNV formation. The patient then received three injections of intravitreal bevacizumab monthly. At last followup, her VA improved to 20/40, with fluid resolution (on OCT). This led the authors to conclude that “atypical CNV can develop
Atypical CNV can develop as an unnatural course of chronic CSCR due to diffuse RPE (retinal pigment epithelium) loss and Bruch’s membrane damage, authors say.
as an unnatural course of chronic CSCR due to diffuse RPE (retinal pigment epithelium) loss and Bruch’s membrane damage”. They noted that intravitreal bevacizumab successfully treated the CNV and preserved visual function in this patient.
The good, the bad . . . and the internal limiting membrane Though the internal limiting membrane (ILM) is often blamed as a culprit for a variety of vitreoretinal pathologies, this thin acellular membrane is both multifaceted and important in posterior surgery. For example, ILM peeling is done in epiretinal membrane removal, in macular pucker and in diabetic macular edema, while ILM transplantation is used for large macular holes, persistent macular holes and in optic disc pit maculopathy. In an e-poster titled 2 Faces of the Internal Limiting Membrane: The Culprit and the Unsung Hero, Dr. Srinivas Joshi and colleagues conducted a prospective study of 51 eyes of 50 patients with large macular holes (>400μm) and macular holes associated retinal detachments (MH-RD). The authors reported that a 25-gauge pars plana vitrectomy was performed. In cases of MH-RD, the ILM flaps were trimmed and placed one-over-the-other on the macular hole (intra-op OCT guided), and under perfluorocarbon liquids (PFCL). In cases of persistent macular hole, dispersive viscoelastic was injected in the hole and the ILM was harvested from adjacent area and stuffed into the hole. Meanwhile, for optic disc pit maculopathy, the ILM was harvested similarly and stuffed into the disc pit. Results showed that 46/51 eyes (90.1%) had type 1 hole closure; 4/51 eyes (7.8%) had type 2 closure; and one eye (2.1%) did not show closure. There were nine cases of persistent
According to authors, though ILM causes tangential traction and has been implicated as a culprit in retinal pathologies, it bridges tissue defects in retinal surgeries and is the real unsung hero.
macular hole – eight of which showed type 1 closure. The six cases of optic disc pit maculopathy showed complete resolution of subretinal fluid after ILM transplant. This led the authors to conclude that “though ILM causes tangential traction and has been implicated as a culprit in retinal pathologies, it bridges tissue defects in retinal surgeries and is the real unsung hero.”
Clinical pearls abound, straight from the experts Expert panels are available during the main symposia (and the free paper sessions) at the APAO 2019 Bangkok to discuss various topics such as: the latest in the management of anterior segment surgery complications pertaining to the posterior segment; unmet needs in retinal diseases; updates in diabetic retinopathy; current trends in macular edema management; updates on AMD and variants, including PCV; pediatric retina surgery essentials; controversies in surgical retina and mystery retinal cases; advances and the future in DME treatment. Challenging cases will be discussed in most of the sessions, including the role in advanced imaging and diagnostics (i.e. 3D experience). Editor’s Note: Media MICE Pte Ltd, PIE Magazine’s parent company, is the official media partner at APAO 2019 Bangkok.