APVRS 2015 Cutting Edge Innovations in Retina

Sydney’s APVRS meeting, described as the “main supranational organisation for this ophthalmic speciality in the region” by Congress President Professor Ian Constable, was co-hosted by the Royal Australian and New Zealand College of Ophthalmologists and the Australian New Zealand Society of Retinal Specialists. Now in its 10th year, APVRS continues to provide a forum for vitreoretinal specialists to keep updated on dynamic changes in technologies and treatments in this sub-specialty. It is also a great opportunity for networking and collaborating with global peers.

APVRS congress convenor Dr. Andrew Chang was thrilled with the response to this year’s meeting announcing “we have over 1,100 registrants (including industry) with 150 speakers from 20 countries.”

Impressive numbers but hardly surprising given the quality scientific program,
which comprised:

One of the current challenges facing ophthalmology is the increasing burden on patients, physicians and the health system of intravitreal injections

• 17 symposia featuring over 100 international and Australian speakers;
• Four rapid fire sessions featuring 46 oral presentations;Six sponsored symposia;
• 72 hard copy posters;
• 109 electronic posters;
• The APVRS Yasuo Tano Lecture delivered by Prof Tien Wong; and
• The ANZSRS Neil Della Lecture, delivered by Prof Ian McAllister.

Cutting Edge Innovations

The symposia began with cutting edge innovations in retina. One of the current challenges facing ophthalmology is the increasing burden on patients, physicians and the health system of intravitreal injections. A/Prof. Jennifer Kang-Mieler discussed the application of an intravitreal microsphere thermo-responsive hydrogel delivery system, which can provide a controlled release of ranibizumab for up to 200 days. If this can be translated to clinical practice, the implication for simplifying treatment and reducing
burden would be significant.

Bionic Devices

Experiences with bionic devices were also discussed with A/Prof Thiyan Jayasundera discussing the Argus II implant designed for patients with retinitis pigmentosa and Leber’s congenital amaurosis. He focused on the challenges with surgery and the complications that can be encountered with the implant and the successes of the first 130 implanted devices.

Dr. Penelope Allen discussed inspiring Australian experiences with a suprachoroidal implanted device and demonstrated, through video footage, the navigation abilities of one patient following the implant. As long term data and real-world experiences with these prostheses emerges, visual rehabilitation of patients without navigating vision may soon be a possibility. Prostheses may not be the only option for patients with retinitis pigmentosa with A/Prof. Yoko Ozawa from Tokyo presenting a method of inducing pluripotent stems cells into rod photoreceptors and better understanding the pathogenesis of the condition through their use.

Gene Therapy

The president of the APVRS, Prof. Ian Constable, discussed the prospects of gene therapy for AMD and early human experiences with a subretinal injection of a virus mediated expression of VEGF receptor one. The study showed promising therapeutic results and a good safety profile, being the result of over a decade of work with animal models. These kinds of therapies have the ability to provide even longer lasting efficacy

Nanosecond Laser

While intravitreal injections have revolutionised the therapy of neovascular AMD, there may be a role for laser therapy for the management of dry AMD as Prof. Robyn Guymer from Melbourne discussed. Nanosecond laser was shown to be effective in reducing drusen load as well as improving visual function in a one-year pilot study providing a potential new avenue in management for these patients we currently have no approved treatments for.

Posterior Segment Oncology

The symposia about posterior segment oncology showed how the diagnosis and monitoring of these malignancies has been revolutionised through the use of wide-field imaging and angiography. These techniques allow for better characterisation and progression of these conditions and allow for evaluation of treatment response, including after endoresection as discussed by Dr. Gerard McGowan.

Retinopathy of Prematurity

The management of paediatric retinal conditions with a focus of retinopathy of prematurity was explored with key presentations about the applications of telemedicine in screening and the role of laser and anti-VEGF medications in the management of this condition.

Neil Della and Yasuo Tano Lectures

The first day concluded with the two prestigious named lectures. Prof. Ian McAllister gave the Neil Della lecture and discussed the history of and the management of retinal vein occlusion. The use of laser-induced vein bypass for CRVO was detailed as well as the use of anti-VEGF therapy for odematous complications. He concluded by describing the future diagnosis and prognostication of this condition through the use of OCT angiography. Prof. Tien Wong of Singapore highlighted the increasing public health problem that is pathological myopia in the Yasuo Tano lecture. The successes in the management of myopic choroidal neovascularization and the ability to potentially cure this condition through the use of anti-VEGF drugs was highlighted.

Diabetic Retinopathy

In the era of intravitreal therapy for diabetic macular oedema, there remains a role for the use of lasers in the management of this condition as discussed by Dr. Victor Chong from the United Kingdom. Micropulse laser therapy targets the retinal pigment epithelium without causing thermal damage to the neural retina and can lead to anatomical improvements. These lasers can be an important tool in the management of DME, as well as its more treatment resistant phenotypes.

Intraocular Steroids

Patients who don’t respond to anti-VEGF therapy may have other inflammatory cytokines driving their disease and intraocular steroids are a treatment option for them as Prof. Sobha Sivaprasad from Moorfields explained. Though there are intraocular devices available to deliver slow release of steroids, caution must be exercised using this therapy with an awareness of the risk of steroid induced raised intraocular pressure and inevitable cataract progression.

New Imaging Modalities

New imaging modalities for retina are in the pipeline with early experiences with OCT angiography being presented by Dr. Fred Chen from Western Australia and Dr. Praveen Patel from Moorfields in London. The ability to image and assess the retinal vasculature through non-invasive techniques is an exciting prospect and hopefully this technology will become readily available in the coming months. Adaptive optics was also a focus of the imaging symposia. While the number of pixels on fundus cameras is increasing, the improvement in the resolution of retinal images has been modest owing to ocular aberrations as Dr. Yasuki Ito from Nagoya explained. Adaptive optics can reduce the effect of these optical aberrations and make even cellular imaging of individual cone cells possible as Prof. Lyndon Da Cruz of Moorfields explained. This imaging can help practitioners assess if there are viable photoreceptors when considering retinal pigment epithelium transplantation in the future.

Pathological Myopia

Myopic macular degeneration, which affects healthy younger people, is a leading cause of blindness worldwide. The incidence of myopia continues to increase, suggesting external influences in the pathogenesis of the problem. Complications of myopia are becoming more frequently encountered and the monitoring of these changes and when to intervene with surgery were discussed by Dr. Andrew Chang from Sydney. Novel surgical techniques were described by Prof. Chi-Chun Lai from Taiwan as well as Dr. Barbara Parolini from Italy. Dr. Parolini provided an interesting insight into the approach to myopia, advising delegates to consider it a condition where axial elongation causes the sclera to detach from the retina rather than vice-versa. With this type of approach, she described successes with a novel macular buckle, which aimed to bring the sclera closer to the retina, thus shortening the eye and addressing this key pathology.

Electrophysiology and Genomics

The interaction between electrophysiology and genomic medicine can play an important role in the clinical diagnosis of retinal dystrophies and the diagnostic challenges were explored in an expert led symposium. With the ever increasing ability to identify genomic changes in the patient, the functional assessment of the visual system provided by electrophysiology can direct specialists on when and how to appropriately utilise genetic testing, as illustrated by A/Prof Robyn Jamieson through a case report.

AMD and Polypoidal Vasculopathy

Dr. Adrian Koh from Singapore started the session with an update on multimodal imaging of polypoidal vasculopathy. Diagnosis of PCV depends on imaging studies including stereo colour fundus photographs, fluorescein angiography, indocyanine green angiography (ICGA), and optical coherence tomography. Of these image studies, ICGA remains the gold-standard for diagnosis of PCV. Dr. Koh had advised that new lesions presenting with a pigment epithelium detachment should always be investigated by indocyanine green angiography to confirm or exclude the presence of a polyp.

Professor Robyn Guymer provided the audience with insights and ideas on the potential of multimodal imaging on preceding lesions or precursors of geographic atrophic, this was termed ‘nascent geographic atrophy’. Professor Shibo Tang from China provided some insights into the role of vascular and non-vascular endothelial growth factors in the pathogenesis of polypoidal choroidal vasculopathy. Dr. Sobha Sivaprasad from the Moorfields Eye Hospital presented on the prognostic indicators of wet age-related macular degeneration. Tubulation, macular fibrosis and geographic atrophy were among risk factors for poor visual prognosis in these patients. Therapeutic options for wet age-related macular degeneration and polypoidal choroidal vasculopathy was discussed by Dr. Timothy Lai and Dr. Jennifer Arnold, followed by a session on future emerging therapies for wet AMD and GA by Dr. Victor Chong. According to Dr. Chong, there is a potential for future therapies targeting the complement pathway for dry AMD.

Macular Surgery

Ocriplasmin (Jetrea) a newly available therapeutic option for the treatment of vitreomacular traction was presented. This has recently been approved for use in Australia and may reduce the need for vitrectomy surgery in some patients. Dr. Greg Kokame from Hawaii, USA enlightened us with his experience with ARGUS II for Blindness from Retinitis Pigmentosa. He reported that with good patient selection and rigorous rehabilitation, early results have been promising with the patient experiencing improved quality of life and better recognition of objects.

Dr. Yuki Morizane from Japan demonstrated a new vitrectomy surgery technique utilising internal limiting membrane transplantation in macular hole surgery. The transplantation of the internal limiting membrane provided a scaffold for cell migration and hole closure. These had applications in large macula holes and chronic macula holes with demonstrated success after failed initial surgical attempts. Other techniques for macular hole closure were also demonstrated by Dr. Oh-Woong Kwon and Dr. Soon Kim. Dr. Hiroko Terasaki demonstrated the use of intraoperative optical coherence tomography (OCT) useful in vitrectomy surgeries. The availability of OCT built-in to the operating microscope enables surgeons to have live imaging of the nerve fibre layer integrity that may be useful during epiretinal membrane peeling and internal limiting membrane peeling. Dr. Kazuhito Yoneda showcased his experience with the use of 27 Gauge Vitrectomy systems and bimanual techniques for vitrectomy surgery.

Posterior Uveitis

Speakers at this symposium provided insights into the various causes of posterior uveitis. Dr. William Mieler presented on injection-associated endophthalmitis.

This is of great relevance given the increasing use of intravitreal injections for the treatment of various retinal diseases. There were interesting presentations on infection-related posterior uveitis including causes such as Klebsiella endophthalmitis, HIV-related uveitis and Tuberculosis. Dr. Lyndell Lim presented an engaging talk on the biologic therapies available for the treatment of Behcets Disease. Dr. Stephen Teoh discussed the strategies on how to manage retinal detachment in viral retinitis, which can occur quite commonly with the condition.

Eyes, Body and Mind

Panelists at an Eyes, Body and Mind Symposium, chaired by Macular Disease Foundation Australia CEO Julie Heraghty discussed important public health areas related to eye disease. Prof. Paul Mitchell and Prof. Matthew Peters from Sydney, Prof. John Dixon from Melbourne, Dr. Meredith Tavener from Newcastle and Dr. Bridianne O’Dea from Black Dog Institute discussed the issues and challenges related to obesity, smoking, ageing and mental health; the significance in eye disease and the development of public policy.