Hot topics – AAO 2017 – New Orleans, 11-14 Novembro

  • 20 de novembro de 2017
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1. Sessão de debates

·         Displacement of submacular hemorrhage in AMD improves visual outcomes: PRO 32%  CON 68%

·         Widefield imaging is necessary in practice: PRO 40%  CON 60%

·         Chandelier scleral buckling (técnica invasiva para visibilização do buckle através de Chandelier e BIOM) is better than conventional SB: PRO 21%  CON 79%

·         Internal limiting membrane flaps are needed to optimize macular hole closure: PRO 23%  CON 77%

·         27 gauge vitrectomy is an essential platform: PRO 30%  CON 70%

 

2. Oito importantes regras para avaliação do linfoma de retina e vítreo (José S. Pulido, Minnesota, EUA)

2.1. Get the nomenclature right: intraocular lymphoma really are three subtypes

·         There are vitreoretinal lymphomas-mainly diffuse large B cell

·         Choroidal lymphoma mainly differentiated B cell (occasionally large B cell)

·         Iridial lymphoma

·         We are going to concentrate on vitreoretinal lymphoma (VRL)

2.2. An eye with vitreous cells and no cystoid macular edema: then think of VRL; reverse does not hold especially if an eye has had prior treatment or intervention.

2.3. VRL does not extend past Bruch’s membrane into choroid. So no need to biopsy the choroid.

2.4. If there are plenty of cells in the vitreous, that’s great; but if not then go to retina as well Corollary: regardless, get plenty of cells; aspirates won’t do.

2.5. MYD88 L265P PCR is one test that you need to do: positive in 90% of cases. If positive from a vitreous or retina biopsy, there’s nothing else that it can be.

2.6. You never win; you can only keep the lymphoma in abeyance.

2.7. Vitrectomy helps make the diagnosis and also debulks; it also might change the environment but sometimes lymphoma comes back.

2.8. Now there are drugs that penetrate the blood-brain and blood-retina barriers: Lenalidomide, Imbruvica.

2.9. Don’t forget the rest: MRI of brain at the time of first evaluation by you and every three months.

·         Conclusions: we are getting better at making the diagnosis; MYD88 L265P is helpful in that regard. Patients are living longer. Treatment has to be tailored to the fact that patients are living longer and recurrences do occur.

 

3. Drusenoid pigment epithelial detachment (DPED) – lifecycle (Lawrence A. Yannuzzi, New York, EUA)

·         Clinical features: elderly, Caucasian, central, lobular appearance, bilaterality, non-vascular, no hemorrhages: no response to anti-VEGF, normal choroid, vitelliform (mixed lipid and hydroxyapatite) detachment and RPE migration, RPE changes, no rips, confluence of large soft drusen, lesion may start as small drusen, some drusen have resolution (in 5 years, 68% will collapse; of those, 92% have atrophy and about 50% are vitelliform), migration of RPE (see dots in the neurosensorial retina), wrinkled RPR.

·         Summary: better understanding of lifecycle of DPED, little about genesis, less is known about the resolution.

 

4. Genetics of retinoblastoma (Carol Shields, Philadelphia, EUA)

·         Prototypical “genetic cancer”.

·         Rb I mutation on chromosome 13.

·         Clinician: familial vs sporadic; bilateral vs unilateral.

·         Germline vs somatic: relies on genetic analysis: test the tumor and the blood; if positive for tumor and blood = germline; if positive only tumor = somatic.

·         tumor multiplicity, tumor laterality, cancer risks (brain, systemic), transmission to offspring (50% transmission to progeny).

·         Germline = trouble: bilateral, pinealoblastoma, second cancers, transmission to offspring.

·         Somatic = unilateral, unifocal, no pinealoblastoma, no second cancers, no transmission.

·         Pinealoblastoma: now 44% of survival; high doses of QT.

·         Others cancers: with external beam radiation (EBRT) 22% redution and  chemoreduction (CRD) 4%.

·         Preimplantation genetic diagnosis (PGD https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1954798) – in vitro fertilization and at the 8 cells stage (morula) take single cell to genetic test, and if negative then implant.

·         Testing: who = all; what = blood and tumor; where = www.genetests.org; when = after we get treatment underway; why = important understand the genetic risks.

·         Three important points about genetic: mosaic Rb, low penetrant Rb, MYCN Rb.

·         We don’t always need tumor sample!

 

5. Drusen and choroidal thickness (Richard Spaide, New York, EUA)

·         Drusen are the first identified sign of non-exudative AMD.

·         OCT to correlate choroid and drusen.

5.1. If very thin choroid: often no drusen or SDD.

5.2. Thin choroid: SDD (38 micra).

5.3. Normal choroid: soft drusen (253 micra).

5.4. Thick choroid: may be pachydrusen (>350-500 micra).

·         Some studies about drusen and AMD: Gemmy Cheung, MD (Singapore): pachydrusen have statistically significant associated with PCV.

6. OCT Angiography (OCTA) (Philip Rosenfeld, Miami, EUA)

·         OCTA provides structural and flow information from a single volume scan.

·         Detects subclinical neovascularization in AMD long before exudation occurs.

·         Detects evidence to re-treatment with anti-VEGF even before obvious exudation recurs on structural OCT imaging.

            – Growth of CNV is not iqual exudation.

            – Kaplan-Meier plots: 3.6% early detection with OCT and 21.1% with   

             OCTA

·         Can be used to detect all types of NV in AMD and PCV and helps guide antiVEGF therapy.

·         Early detects RAP (type 3 NV).

·         Excludes CNV when drusen + fluid present.

·         Provides multimodal imaging by using just one imaging modality.

·         It’s fast, safe, easily repeated at F/U.

·         Great research tool.

 

7. VVPP + faco concomitante vs. cirurgia sequencial: Há diferença nos resultados? William Mieler (Chicago, EUA)

 

·         112 olhos consecutivos (VVPP + faco concomitante); seguimento mínimo de 6m. Várias indicações. 

·         Riscos: avaliar cálculo da LIO. 

·         Problemas potenciais: reembolso menor da cirurgia pelo convênio. Custo menor pago pelo paciente (~20%).

·         Conclusão: operação única, com custo-benefício adequado, rápida recuperação visual. 

 

 

8. Quando e como tratar maculopatia miópica tracional. Hiroko Terasaki (Nagoya, Japão)

 

·         n=79 olhos. 

·         Classificação: #1. retinosquise isolada; #2. buraco macular lamelar; #3. descolamento foveal; #4. buraco macular lamelar + descolamento foveal.

·         Resultados: 1. Melhora da acuidade visual: todos os subtipos, exceto retinosquise isolada. Correlação positiva entre AV pré e pós-operatória. Olhos com descolamento foveal (DF) tiveram pior AV pós-op. em relação a olhos sem DF. Complicação: buraco macular total: ~5% (exceto nos olhos com retinosquise isolada). 

·         Técnica cirúrgica: remover hialoide posterior e MLI (não realizar o ‘peeling da MLI na fóvea – reduz o risco de buraco macular total).

 

 

9. Tratamento cirúrgico da maculopatia secundária à fosseta de nervo óptico (Optic pit maculopathy). Mark Johnson (Ann Arbor, EUA)

 

9.1. Buckle macular: resultados bons em alguns grupos, mas muito pouco utilizado.

9.2. VVPP isolada: risco maior de insucesso.

9.3 . Laser justapapilar na área da fosseta (feito na lâmpada de fenda, no pré-op. imediato – consegue ajustar a dose do laser no EPR, sem danificar a retina interna) + VVPP com remoção da hialoide posterior (sem peeling da MLI) + gás (7-10 dias de prone posição):  é a técnica recomendada pelo autor.

9.4. VVPP + remoção da hialoide posterior + fechamento da cavitação com fragmento autólogo de esclera: alguns relatos na literatura; a cavitação precisa ter tamanho suficiente. Resultados a longo prazo e segurança são pouco conhecidos.

9.5. Adjuntos da VVPP: #1. peeling MLI: risco de b. macular e sem racional plausível;  #2. fenestração da retina interna: selamento espontâneo rápido. Sem indicação. #3. Cola de fibrina ou flap invertido de MLI na cavitação: sem vantagem teórica nos olhos com fluido com origem SNC. Seguimento a longo prazo insuficiente. 

 

 

10. Opções de tratamento para a síndrome de tração vitreomacular. Robert Avery (Santa Barbara, EUA)

 

10.1. Vitrectomia + remoção hialoide posterior: gold-standard.

10.2. Ocriplasmina:  problemas relacionados ao custo e segurança. Melhores resultados em casos selecionados.

10.3. Vitreólise pneumática: menor custo, bons resultados, ainda poucos estudos com esta técnica.

10.4. Observação: com pequena superfície de tração e boa AV.

10.5. Conclusão: Boa AV, sem muitos sintomas: observação; área extensa de adesão: VVPP. Outros casos: poderia iniciar com procedimento mais simples (vitreólise). 

 

 

11. Anti-VEGF para retinopatia da prematuridade (ROP). Paul Chan (Chicago, EUA)

 

11.1. Eficácia na regressão da ROP com indicação terapêutica.

11.2. Casos com indicação: #1. Zona I; #2. Zona II posterior; #3. ROP agressiva posterior (APROP).

11.3. Riscos futuros ainda não são conhecidos (indicação deve ser compartilhada com os familiares).

11.4. Necessidade de seguimento pós-operatório contínuo.

 

 

12. To peel or not to peel the ILM in ERM surgery (Lihteh Wu, San Jose, Costa Rica)

 

·         Sivalingam e cols, Ophthalmology 1990;97:1549-52: 41 eyes underwent PPV and membrane peel; histopathologic specimens were analyzed; presence of long segments of ILM in the histopathologic specimen indicated a less favorable visual outcome.

·         Park e cols, Ophthalmology 2003;110:62-4: ILM peeling during ERM removal does not have deleterious effects; ILM peeling associated with a low recurrence rate; resolution of retinal folds.

·         Liu e cols, J Ophthalmol 2015: meta-analysis of 8 studies; ILM peeling did not show an added benefit in terms of better visual outcomes; ILM peeling did not lower the recurrence rate.

·         Chang e cols, JAMA Ophthalmol 2013;131:525-30: retrospective comparative series of eyes with ERM that underwent single vs Double peeling; more complete ERM removal with double peeling vs single peeling; no difference in BCVA between single and double peeling; greater proportional decrease in central macular thickness in single peeling vs double peeling; trauma?

·         Ripandelli e cols, Retina 2015;35:498-507: number of microscotomas significantly greater in eyes where ILM was peeled in comparison to those eyes where the ILM was not peeled.

·         Summary: ILM peeling does not offer any visual acuity improvement over no ILM peeling; ILM peeling reduces the recurrence rate but many recurrences are not clinically important; currently unclear IF ILM peeling is detrimental to the eye; rare complications associated  to ILM peeling have been reported (eccentric MH, retinal thinning and microscotomata); error in the side of caution and do not peel ILM routinely, only in cases of high risk of recurrence.

 

 

13. Treatment of optic disc maculopathy. Mark Johnson (Ann Arbor, EUA)

 

A. Cavitary optic disc anomalies associated with macular fluid/detachment can be of three types:

            1) Typical optic disc coloboma.

            2) Optic pit and atypical coloboma.

            3) Morning glory disc anomaly.

B. Theories of pathogenesis

            1) Fluctuating pressure gradients along anomalous communications

               within disc cavitation induce migration of fluid into adjacent retinal

               tissue.

                        a) Schisis-like intraretinal fluid connecting with the optic disc –

                          universal finding.

                        b) Fluid eventually percolates into subretinal space in many

                          eyes.

                        c) Rare patients exhibit subretinal fluid alone.

            2) Evidence for fluctuating pressure gradients.

                        a) Subretinal migration of vitreous substitutes (gas, silicone oil,

    heavy liquid).

                        b) Vitreous gel incarceration into disc cavitation.

                        c) Spontaneous waxing and waning of macular fluid.

                        d) Observation of vitreous debris moving in and out of cavitation

    with digital pressure on globe.

            3) Source of macular fluid – may be vitreous fluid, cerebrospinal fluid,

               or mix of both.

C. Therapeutic implications of pathogenesis/pathoanatomy

            1) Factors that alter pressure gradients affect macular fluid (carbonic

               anhydrase inhibit).

            2) Permanent cure likely requires barrier to intraretinal/subretinal fluid

               migration from disc.

 

 

14. The latest on central serous retinopathy management. Francine Behar-Cohen (Paris, FR)

A. Factors affecting duration of first episode:

            1) Central thickness larger than 500 micra.

            2) RPE elevation larger than 50 micra.

            3) Age older than 40 years-old.

B. Recurrences is major problem, rate of recurrence 20-50%.

C. Trigger factors of recurrence:

            1) Irregular RPE.

            2) Subretinal hyperreflectivity.

            3) History of psychiatric illness.

D. IF recurrence occurs in short interval after first episode, prognosis is worse.

E. Author explained mechanisms of pathogenesis of disease; she defends use of mineralocorticoid inhibitor. In addition, for non-responder of mineralocorticoid inhibitor, she proposed use of topical dexamethasone.

 

 

15. The pharmacokinetics of anti-VEGF agents – Pharmacokinetic study of intravitreal aflibercept in humans with neovascular AMD. Diana Do (Palo Alto, EUA)

 

A. Purpose: to investigate the ocular pharmacokinetics of aflibercept after a single intravitreal injection in humans with neovascular AMD.

B. Five eyes from 5 individuals with new-onset neovascular AMD and no history of vitrectomy surgery were enrolled.

C. At baseline, aqueous humor and blood plasma samples were taken from all participants. Immediately after the samples were obtained, all study eyes received a single intravitreal injection of aflibercept, and this time point was designated as Day 0.

D. Study eyes underwent sampling of aqueous humor and blood plasma at 6 additional study time points: 4 hours after injection and Days 1, 3, 7, 14, and 28.

E. Concentrations of free and bound aflibercept were quantified using enzyme-linked immunosorbent assay.

F. The average of half-life of free aflibercept measured in the aqueous after intravitreal injection was found to be ~ 9 days.

G. Plasma levels of free aflibercept were low to undetectable during the first week following injection, and undetectable in all patients at time points beyond 7 days.

 

 

16. OCT Angiography (OCT-A) in the management of AMD and polypoidal choroidal vasculopathy. Philip Rosenfeld (Miami, EUA) and Elie Motulsky (Miami, EUA)

 

A. OCT-A is a powerful, noninvasive imaging strategy for the diagnosis of macular NV.

B. SS-OCT-A appears to be superior to SD-OCT-A for the visualization of neovascular lesions under the RPE.

C. Different en face imaging strategies and retinal vessel projection artifact removal algorithms have been developed to help facilitate the diagnosis and characterization of macular NV.

D. While the outer retinal to choriocapillaris (ORCC) slab is an ideal screening strategy for determining the presence of NV, more refined segmentation strategies are useful to further locate the NV as being above or below the RPE.

E. Currently, OCT-A has proven very useful in assessing whether macular NV is present, but it remains unclear whether the en face flow images from OCT-A provide any additional value over the OCT structural images when determining retreatment with anti-VEGF therapy.

F. The combination of en face flow and structural images, along with the different segmentation strategies used to visualize macular NV and macular fluid, clearly demonstrate that OCT-A provides multimodal imaging from a single imaging modality, and all these images are provided from a single OCT scan.

G. OCT-A provides structural and flow information from a single volume scan.

H. OCT-A may detect subclinical NV in AMD before exudation occurs.

 

 

17. Update on hemorrhagic occlusive retinal vasculitis after cataract surgery (HOCRV). Dean Eliott (Boston, EUA)

 

A. Histologic and immunophenotyping findings of 2 patients with HOCRV.

B. The disease may not be leukocytoclastic retinal vasculitis, but rather a:

            1) Primary non-granulomatous choroiditis.

            2) With secondary retinal vasculopathy.

            3) With diffuse hemorrhagic necrosis of neurosensory retina.

            4) With intraluminal retina vascular thrombosis.

            5) With diffuse choroidal infiltration of inflammatory cells.

            6) Iris and ciliary body infarction # predominance of CD8+ and CD4+ T

               cells in choroidal infiltrate.

C. The choroiditis is predominantly T-cell driven and a type IV rather than type III drug hypersensitivity.

D. FDA recommends against use of intraocular vancomycin during cataract surgery. http://www.retina-specialist.com/article/as-fda-issues-horv-warning-histology-gains-clarification.

 

 

18. Paraneoplastic retinal conditions. Anita Agarwal (San Francisco, EUA)

 

 

A. Paraneoplastic disorders

            1) Benign diffuse uveal melanocystic proliferation (BDUMP).

            2) Cancer-associated retinopathy.

            3) Melanoma-associated retinopathy.

            4) Paraneoplastic vitelliform maculopathy.

            5) CRMP5-associated Rod cone degeneration.

B. Cancer-associated retinopathy

            1) Often predates the diagnosis of cancer.

            2) Presents with acute onset of photopsias and rapidly progressive

               night blindness evolving into day and night blindness, difficulty with

               central vision and color vision.

            3) Associated antibodies

                        a) Recoverin (23 kDa)

                        b) Enolase (46 kDa)

                        c) Arrestin (48 kDa)

                        d) Carbonic anhidrase II (CAII, 30 kDa)

                        e) Tubby-like protein 1 (TULP1, 78 kDa)

                        f) Interphotoreceptor retinoid-binding protein (IRBP, 145 kDa)

                        g) Heat shock cognate protein 70 (hsc-70, 70 kDa)

                        h) Photoreceptor cell-specific nuclear receptor (PRN, 41 kDa)

                        i) Photoreceptor cell-specific nuclear receptor (PNR, 41 kDa)

            4) Fundus normal initially; later: retinal pigment epithelial mottling,

               vascular attenuation.

            5) Histology: loss of photoreceptors.

 

 

19. Panel about challenging cases in neovascular AMD – Take home messages

 

A. Redução para intervalo quinzenal: primeira medida se não houver resposta a anti-VEGFs; procurar outros fatores que podem impedir a resposta a anti-VEGF, como tração macular.

B. Uso de latanoprosta causa edema macular; retirar em pacientes com AMD neovascular.

C. CNV tipo 1: quando exsuda, começa com líquido sub-retiniano.

D. Sangramento sub-retiniano pós-CNV: observar, injetar gás, anti-VEGF, TPA ou cirurgia. Principal fator prognóstico é o tempo.

E. Rotura de EPR pode causar sangramento. Anti-VEGF não é causa da rotura.

F. Deixar um pouco de liquido pode ser benéfico para evitar atrofia. “Não dê check-mate na CNV; deixe-a somente em check-perpétuo”.

G. Sinal da dupla-linha próxima do EPR pode significar CNV oculta.

H. Quantidade de VEGF e o local da produção inflencia onde vai estar o líquido sub-retiniano ou intrarretiniano.

I. Cistos intrarretinianos podem indicar prognóstico ruim. Se sumirem, melhor; se persistirem, apesar do tratamento, pode significar fibrose e pior prognóstico.

J. PED fibrovascular costuma responder melhor a aflibercept; motivo ainda incerto, pode ser afinidade ou bloqueio de outros membros da família VEGF-PIGF.

L. Máximo de “treat and extend”: 3 meses. Pelo resto da vida, tratar a cada 3 meses, mesmo sem líquido, ou visitas de controle a cada 4-6 semanas; paciente escolhe.

M. Empresa dos EUA desenvolvendo OCT home monitoring: device semelhante a óculos, não fornece imagem da retina, mas detecta quando espessura da retina aumenta 30 micra.

 

 

20. SD-OCT vs SS-OCT. Jay Duker (Boston, EUA) e Carl Rebhun (Boston, EUA)

·         SS-OCT requires narrow linewidth, high-speed, frequency-swept lasers that are very expensive. In general, SS-OCT devices use a longer wavelength than SD-OCT. Both 1000-nm and 1300-nm wavelengths have been utilized.

·         Clinical advantages of SS-OCT: faster acquisition speed, wider scanning range (12-mm to 16-mm scan), possible to image vitreous and choroid well simultaneously, longer wavelength (better ability to penetrate choroid, lens opacity, vitreous debris, pigmented epithelial detachments).

·         Disadvantages of SS-OCT: increased cost of light source, worse signal-to-noise ratio, worse motion artifact.

·         SS-OCT divises

            1) Topcon: DRI (Deep Range Imaging) OCT Triton

                        a) 100.000 A-scan per second

                        b) 1050nm wavelength

                        c) 12mm scan length

                        d) multimodal image: color, red-free, FA, FAF, posterior OCT,

                          anterior OCT, OCT-A

            2) Zeiss; Plex Elite 9000

                        a) 100.000 A-scan per second

                        b) 1060nm wavelength

                        c) 16mm scan length

                        d) montage software

·         SS-OCT has theoretical advantages (increased speed, deeper penetration, better ability to image through opaque media) and disadvantages (worse axial resolution, worse signal-to-noise ratio, and more expensive) compared to SD-OCT.

·         SS-OCT will allow for increased field of view with widefield imaging. In addition, with increased A-scan acquisition speed there will be better resolution of larger scans.

 

 

21. Widefield OCT and OCT-A. Nadia Waheed (Boston, EUA)

 

·         When we increase the scanning area, we can see loss of resolution of the vasculature.

·         To overcome this issue, it’s possible to increase the scanning speed (SS-OCT) or to use smaller scans áreas and do montage with the images.

·         Ultra widefield FA still goes further towards the periphery.

·         Be careful with the images in the periphery because when trying to quantify areas of non-perfusion, it’s possible that you’ll find a much larger area than the real one (mercator cartography). It’s possible to correct this distortion with softwares.

·         This distortion isn’t significant to analyze the macular area, but when go outside macula could be a difference of 12-20% in the lesion that you’re imaging or the area of non-perfusion you’re trying to measure.

·         Most commercially available OCT and OCT-A devices have the ability to provide wide field OCT-A (combination of faster speeds, tracking and the ability to montage).

 

 

22. Subclinical diabetic macular changes revealed by OCT angiography. Richard Rosen (New York, EUA)

 

·         While OCT-A currently doesn’t reveal leakage, it can reveal the full spectrum of microvascular retinopathy in multiple capillary beds and detect the loss of even single capillary segments (microaneurysms, vascular loops, non-perfusion, FAZ erosion, venous beading, neovascularization, overlapping capillary beds).

·         Possible to do quantitative analysis, such as multilayer perfused capillary density mapping and foveal avascular zone size and configuration.

·         Studies showed that the capillary distance in OCT-A larger than 60 micra can point to some degree of oxygen insufficiency.

·         Perfused capillary density maps and averages can be used to scale degree of diabetic retinopathy.

·         Patients with diabetic retinopathy has a decrease in the capillary density map as the disease worsens. But there is a point the natural history of the diabetic retinopathy when this perfused capillary density is actually greater than controls. This happened in the diabetic patient without any sign of diabetic retinopathy (this means that this parameter could be useful biomarker between normal and patients with diabetic retinopathy).

·         Non-invasively detect the earliest lesions of diabetic retinopathy prior to visible hemorrhages and microaneurysms.

·         Current anti-VEGF agents have been shown to slow down and even reverse capillary non-perfusion. Newer agents (Tie-2, VAP-1) specifically designed to reverse early capillary closure are currently in early stages of testing.

 

 

23. Redefining atrophy in the era of OCT and multimodal imaging. Srinivas Sadda (Los Angeles, EUA)

 

·         International panel of experts in imaging, histopathology, reading centers.

·         Cases with longitudinal multimodal imaging to allow determination of the first point at which atrophy became evident.

·         Three end-points: 1. Complete/end-stage atrophy; 2. Incomplete/partial atrophy/ 3. No atrophy but high-risk features.

·         Four new terms were introduced:

            1) Complete RPE + outer retinal atrophy (c-RORA), defined by the

               following (all criteria required):

a)    Presence of hypertransmission of equal or > 250 micra

b)    Presence of a zone of attenuation/disruption of RPE, basal laminar (BL) complex of equal or > 250 micra

c)    Evidence of overlying photoreceptor degeneration whose features include all of the following: outer nuclear layer thinning, external limiting membrane loss, ellipsoid zone/interdigitation zone loss

2) Incomplete RPE + outer retinal atrophy (i-RORA), defined by the following (all criteria required):

            a) Some hypertransmission must be present, but often

               discontinuous

            b) Some irregularity of RPE A} BL complex

            c) Detectable photoreceptor degeneration, signs of which can

               include “wedge”, “subsidence”

            d) Absence of signs of an RPE tear

3) Complete outer retinal atrophy defined by the following (all criteria required):

            a) Continuous loss of ellipsoid zone

            b) Severe thinning of outer retina

            c) Intact RPE band

4) Incomplete outer retinal atrophy defined by the following (all criteria required):

            a) Subretinal drusenoid deposits with detectable elllipsoid zone

            b) Detectable thinning of the outer retina

 

 

24. Disease expression in AMD is correlated with choroidal thickness. Richard Spaide (New York, EUA)

 

·         Later OCT imaging and histopathology both showed pseudodrusen were collections of material under the retina (not under the RPE), called “subretinal drusenoid deposits” (SDD).

·         SDD were found to be associated with thin choroids, while soft drusen were associated with normal-thickness choroids.

·         Pachydrusen: generally greater than 63 micra in diameter, are irregular in shape, have a sharply defined border, and are scattered across the posterior pole.

·         Drusen and pachydrusen are accumulations of extracellular material below the RPE, while pseudodrusen are deposits on top of the RPE.

·         Soft drusen has normal choroidal thicknesses, and pachydrusen are found in eyes with thicker choroids.

·         In asian population, eyes with pachydrusen has higher risk to develop polipoidal choroidopathy.

·         Manifestations of late AMD (CNV type, evolution to geographic atrophy) seems to be related to the extracellular deposits and the thickness of choroid.

·         The presence of SDD is highly associated with the development of outer retinal atrophy, GA, and type 3 neovascularization, an each of these has been, associates with a thinner choroid.

 

 25.  Proliferative diabetic retinopathy (PDR) surgery. André Gomes (São Paulo, Brasil)

 

·         Main goals in surgery for PDR: clear the media, remove all fibrotic tissue and potential residual traction, reduce bleeding, avoid new breaks, reattach the retina, perform epiretinal membrane and or internal limiting membrane removal if needed, apply extensive panretinal photocoagulation, choose the appropriate tamponade when necessary.

·         Recent surgical developments: wide selection of wide-angle viewing systems, new light sources, new machines, microincisional vitrectomy surgery with different gauge options, chromovitrectomy era, anti-VEGF, PFC liquids…

·         What to offer our patients? Segmentation/delamination, “The probe only” technique, bimanual maneuvers, 23, 25, 27 gauges…

 

 

26. Phase 2 trial of ciliary neurotrophic factor (CNTF) for macular telangiectasia Type 2. Emily Chew (Bethesda, EUA)

 

O CNTF tem efeito benéfico e diminui a perda de fotorreceptores nos pacientes com telangiectasia macular tipo 2.

Em comparação com os olhos que não foram tratados com CNTF, houve uma estabilização da acuidade visual nos olhos tratados.

 

 

27. Hypersonic vitrectomy: initial clinical experience. Carl Awl (Nashville, EUA)

 

“Hypersonic vitrectomy” describes a method of vitreous removal in which ultrasonic power is used to drive the vitrectomy probe tip. The tip of the hypersonic vitrectomy handpiece oscillates at a frequency of approximately 1.7 million “cuts” per minute, creating a localized region of tissue disruption just within or at the surface of the port. This phenomenon is termed “hypersonic liquefaction”. The emulsified material is drawn through the probe and out of the eye by conventional vacuum/aspiration methods. However, there exists a phenomenon of low suction that can be induced at the port of the device simply through the action of the hypersonic oscillation. In July 2017, 3 surgeons (Stanga, Agarwal, Venkataraman) used the hypersonic vitrectomy device to perform 22 cases in 20 human subjects. These cases were performed in India, with appropriate oversight and consent. Maneuvers successfully performed during these initial cases included the following:

·         Induction of posterior vitreous detachment

·         Core vitrectomy

·         Peripheral vitrectomy with scleral depression

·         Removal of dense vitreous hemorrhage

·         Removal of retained lens cortex

·         Posterior capsulotomy

·         Aspiration of preretinal blood

An iatrogenic retinal break in an area of mobile detached retina was the sole reported intraoperative complication.

 

 

28. Update on cell-based therapies for atrophic maculopathy. Allen Ho (Philadelphia, EUA)

 

Terapia celular, seja células-tronco ou outro tipo de célula, estão sendo estudadas para os casos de DMRI atrófica.

Há 2 tipos de mecanismo de ação para terapia celular: trófico e regenerativo.

As terapias celulares têm sido bem toleradas nos pacientes com DMRI atrófica.

 

 

29. Anti-VEGF monotherapy vs combination therapy with photodynamic therapy for treatment of polypoidal choroidal vasculopathy. Tien Wong (Singapura)

 

Os resultados do EVEREST-2 e do PLANET mostraram que o tratamento apenas com anti-VEGF seja ranibizumabe ou aflibercept ou o tratamento combinado com PDT resultam em melhora da função visual após 1 ano de tratamento..

O tratamento de escolha depende das características individuais do paciente e do acesso ao PDT.

 

 

30. Subclinical diabetic macular changes revealed by OCT Angiography: why it matters. Richard Rosen (New York, EUA)

 

O OCT angiography tem a capacidade de detectar as lesões mais iniciais da retinopatia diabética, como não-perfusão capilar, possiblitando tratamento específico mais precocemente.

Os agentes anti-VEGF atuais têm demonstrado diminuir ou mesmo reverter a não-perfusão capilar retiniana.

Deixe uma resposta

  • 20 de novembro de 2017
  • Comentário: 0

 

1. Sessão de debates

·         Displacement of submacular hemorrhage in AMD improves visual outcomes: PRO 32%  CON 68%

·         Widefield imaging is necessary in practice: PRO 40%  CON 60%

·         Chandelier scleral buckling (técnica invasiva para visibilização do buckle através de Chandelier e BIOM) is better than conventional SB: PRO 21%  CON 79%

·         Internal limiting membrane flaps are needed to optimize macular hole closure: PRO 23%  CON 77%

·         27 gauge vitrectomy is an essential platform: PRO 30%  CON 70%

 

2. Oito importantes regras para avaliação do linfoma de retina e vítreo (José S. Pulido, Minnesota, EUA)

2.1. Get the nomenclature right: intraocular lymphoma really are three subtypes

·         There are vitreoretinal lymphomas-mainly diffuse large B cell

·         Choroidal lymphoma mainly differentiated B cell (occasionally large B cell)

·         Iridial lymphoma

·         We are going to concentrate on vitreoretinal lymphoma (VRL)

2.2.  eye with vitreous cells and no cystoid macular edema: then think of VRL; reverse does not hold especially if an eye has had prior treatment or intervention.

2.3. VRL does not extend past Bruch’s membrane into choroid. So no need to biopsy the choroid.

2.4. If there are plenty of cells in the vitreous, that’s great; but if not then go to retina as well Corollary: regardless, get plenty of cells; aspirates won’t do.

2.5. MYD88 L265P PCR is one test that you need to do: positive in 90% of cases. If positive from a vitreous or retina biopsy, there’s nothing else that it can be.

2.6.  You never win; you can only keep the lymphoma in abeyance.

2.7. Vitrectomy helps make the diagnosis and also debulks; it also might change the environment but sometimes lymphoma comes back.

2.8. Now there are drugs that penetrate the blood-brain and blood-retina barriers: Lenalidomide, Imbruvica.

2.9. Don’t forget the rest: MRI of brain at the time of first evaluation by you and every three months.

·         Conclusions: we are getting better at making the diagnosis; MYD88 L265P is helpful in that regard. Patients are living longer. Treatment has to be tailored to the fact that patients are living longer and recurrences do occur.

 

3. Drusenoid pigment epithelial detachment (DPED) – lifecycle (Lawrence A. Yannuzzi, New York, EUA)

·         Clinical features: elderly, Caucasian, central, lobular appearance, bilaterality, non-vascular, no hemorrhages: no response to anti-VEGF, normal choroid, vitelliform (mixed lipid and hydroxyapatite) detachment and RPE migration, RPE changes, no rips, confluence of large soft drusen, lesion may start as small drusen, some drusen have resolution (in 5 years, 68% will collapse; of those, 92% have atrophy and about 50% are vitelliform), migration of RPE (see dots in the neurosensorial retina), wrinkled RPR.

·         Summary: better understanding of lifecycle of DPED, little about genesis, less is known about the resolution.

 

4. Genetics of retinoblastoma (Carol Shields, Philadelphia, EUA)

·         Prototypical “genetic cancer”.

·         Rb I mutation on chromosome 13.

·         Clinician: familial vs sporadic; bilateral vs unilateral.

·         Germline vs somatic: relies on genetic analysis: test the tumor and the blood; if positive for tumor and blood = germline; if positive only tumor = somatic.

·         tumor multiplicity, tumor laterality, cancer risks (brain, systemic), transmission to offspring (50% transmission to progeny).

·         Germline = trouble: bilateral, pinealoblastoma, second cancers, transmission to offspring.

·         Somatic = unilateral, unifocal, no pinealoblastoma, no second cancers, no transmission.

·         Pinealoblastoma: now 44% of survival; high doses of QT.

·         Others cancers: with external beam radiation (EBRT) 22% redution and  chemoreduction (CRD) 4%.

·         Preimplantation genetic diagnosis (PGD https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1954798) – in vitro fertilization and at the 8 cells stage (morula) take single cell to genetic test, and if negative then implant.

·         Testing: who = all; what = blood and tumor; where = www.genetests.org; when = after we get treatment underway; why = important understand the genetic risks.

·         Three important points about genetic: mosaic Rb, low penetrant Rb, MYCN Rb.

·         We don’t always need tumor sample!

 

5. Drusen and choroidal thickness (Richard Spaide, New York, EUA)

·         Drusen are the first identified sign of non-exudative AMD.

·         OCT to correlate choroid and drusen.

5.1. If very thin choroid: often no drusen or SDD.

5.2. Thin choroid: SDD (38 micra).

5.3. Normal choroid: soft drusen (253 micra).

5.4. Thick choroid: may be pachydrusen (>350-500 micra).

·         Some studies about drusen and AMD: Gemmy Cheung, MD (Singapore): pachydrusen have statistically significant associated with PCV.

 

6. OCT Angiography (OCTA) (Philip Rosenfeld, Miami, EUA)

·         OCTA provides structural and flow information from a single volume scan.

·         Detects subclinical neovascularization in AMD long before exudation occurs.

·         Detects evidence to re-treatment with anti-VEGF even before obvious exudation recurs on structural OCT imaging.

            – Growth of CNV is not iqual exudation.

            – Kaplan-Meier plots: 3.6% early detection with OCT and 21.1% with   

             OCTA

·         Can be used to detect all types of NV in AMD and PCV and helps guide antiVEGF therapy.

·         Early detects RAP (type 3 NV).

·         Excludes CNV when drusen + fluid present.

·         Provides multimodal imaging by using just one imaging modality.

·         It’s fast, safe, easily repeated at F/U.

·         – Great research tool.

 

7. VVPP + faco concomitante vs. cirurgia sequencial: Há diferença nos resultados? William Mieler (Chicago, EUA)

 

·         112 olhos consecutivos (VVPP + faco concomitante); seguimento mínimo de 6m. Várias indicações. 

·         Riscos: avaliar cálculo da LIO. 

·         Problemas potenciais: reembolso menor da cirurgia pelo convênio. Custo menor pago pelo paciente (~20%).

·         Conclusão: operação única, com custo-benefício adequado, rápida recuperação visual. 

 

 

8. Quando e como tratar maculopatia miópica tracional. Hiroko Terasaki (Nagoya, Japão)

 

·         n=79 olhos. 

·         Classificação: #1. retinosquise isolada; #2. buraco macular lamelar; #3. descolamento foveal; #4. buraco macular lamelar + descolamento foveal.

·         Resultados: 1. Melhora da acuidade visual: todos os subtipos, exceto retinosquise isolada. Correlação positiva entre AV pré e pós-operatória. Olhos com descolamento foveal (DF) tiveram pior AV pós-op. em relação a olhos sem DF. Complicação: buraco macular total: ~5% (exceto nos olhos com retinosquise isolada). 

·         Técnica cirúrgica: remover hialoide posterior e MLI (não realizar o ‘peeling da MLI na fóvea – reduz o risco de buraco macular total).

 

 

9. Tratamento cirúrgico da maculopatia secundária à fosseta de nervo óptico (Optic pit maculopathy). Mark Johnson (Ann Arbor, EUA)

 

9.1. Buckle macular: resultados bons em alguns grupos, mas muito pouco utilizado.

9.2. VVPP isolada: risco maior de insucesso.

9.3 . Laser justapapilar na área da fosseta (feito na lâmpada de fenda, no pré-op. imediato – consegue ajustar a dose do laser no EPR, sem danificar a retina interna) + VVPP com remoção da hialoide posterior (sem peeling da MLI) + gás (7-10 dias de prone posição):  é a técnica recomendada pelo autor.

9.4. VVPP + remoção da hialoide posterior + fechamento da cavitação com fragmento autólogo de esclera: alguns relatos na literatura; a cavitação precisa ter tamanho suficiente. Resultados a longo prazo e segurança são pouco conhecidos.

9.5. Adjuntos da VVPP: #1. peeling MLI: risco de b. macular e sem racional plausível;  #2. fenestração da retina interna: selamento espontâneo rápido. Sem indicação. #3. Cola de fibrina ou flap invertido de MLI na cavitação: sem vantagem teórica nos olhos com fluido com origem SNC. Seguimento a longo prazo insuficiente. 

 

 

10. Opções de tratamento para a síndrome de tração vitreomacular. Robert Avery (Santa Barbara, EUA)

 

10.1. Vitrectomia + remoção hialoide posterior: gold-standard.

10.2. Ocriplasmina:  problemas relacionados ao custo e segurança. Melhores resultados em casos selecionados.

10.3. Vitreólise pneumática: menor custo, bons resultados, ainda poucos estudos com esta técnica.

10.4. Observação: com pequena superfície de tração e boa AV.

10.5. Conclusão: Boa AV, sem muitos sintomas: observação; área extensa de adesão: VVPP. Outros casos: poderia iniciar com procedimento mais simples (vitreólise). 

 

 

11. Anti-VEGF para retinopatia da prematuridade (ROP). Paul Chan (Chicago, EUA)

 

11.1. Eficácia na regressão da ROP com indicação terapêutica.

11.2. Casos com indicação: #1. Zona I; #2. Zona II posterior; #3. ROP agressiva posterior (APROP).

11.3. Riscos futuros ainda não são conhecidos (indicação deve ser compartilhada com os familiares).

11.4. Necessidade de seguimento pós-operatório contínuo.

 

 

12. To peel or not to peel the ILM in ERM surgery (Lihteh Wu, San Jose, Costa Rica)

 

·         Sivalingam e cols, Ophthalmology 1990;97:1549-52: 41 eyes underwent PPV and membrane peel; histopathologic specimens were analyzed; presence of long segments of ILM in the histopathologic specimen indicated a less favorable visual outcome.

·         Park e cols, Ophthalmology 2003;110:62-4: ILM peeling during ERM removal does not have deleterious effects; ILM peeling associated with a low recurrence rate; resolution of retinal folds.

·         Liu e cols, J Ophthalmol 2015: meta-analysis of 8 studies; ILM peeling did not show an added benefit in terms of better visual outcomes; ILM peeling did not lower the recurrence rate.

·         Chang e cols, JAMA Ophthalmol 2013;131:525-30: retrospective comparative series of eyes with ERM that underwent single vs Double peeling; more complete ERM removal with double peeling vs single peeling; no difference in BCVA between single and double peeling; greater proportional decrease in central macular thickness in single peeling vs double peeling; trauma?

·         Ripandelli e cols, Retina 2015;35:498-507: number of microscotomas significantly greater in eyes where ILM was peeled in comparison to those eyes where the ILM was not peeled.

·         Summary: ILM peeling does not offer any visual acuity improvement over no ILM peeling; ILM peeling reduces the recurrence rate but many recurrences are not clinically important; currently unclear IF ILM peeling is detrimental to the eye; rare complications associated  to ILM peeling have been reported (eccentric MH, retinal thinning and microscotomata); error in the side of caution and do not peel ILM routinely, only in cases of high risk of recurrence.

 

 

13. Treatment of optic disc maculopathy. Mark Johnson (Ann Arbor, EUA)

 

A. Cavitary optic disc anomalies associated with macular fluid/detachment can be of three types:

            1) Typical optic disc coloboma.

            2) Optic pit and atypical coloboma.

            3) Morning glory disc anomaly.

B. Theories of pathogenesis

            1) Fluctuating pressure gradients along anomalous communications

               within disc cavitation induce migration of fluid into adjacent retinal

               tissue.

                        a) Schisis-like intraretinal fluid connecting with the optic disc –

                          universal finding.

                        b) Fluid eventually percolates into subretinal space in many

                          eyes.

                        c) Rare patients exhibit subretinal fluid alone.

            2) Evidence for fluctuating pressure gradients.

                        a) Subretinal migration of vitreous substitutes (gas, silicone oil,

    heavy liquid).

                        b) Vitreous gel incarceration into disc cavitation.

                        c) Spontaneous waxing and waning of macular fluid.

                        d) Observation of vitreous debris moving in and out of cavitation

    with digital pressure on globe.

            3) Source of macular fluid – may be vitreous fluid, cerebrospinal fluid,

               or mix of both.

C. Therapeutic implications of pathogenesis/pathoanatomy

            1) Factors that alter pressure gradients affect macular fluid (carbonic

               anhydrase inhibit).

            2) Permanent cure likely requires barrier to intraretinal/subretinal fluid

               migration from disc.

 

 

14. The latest on central serous retinopathy management. Francine Behar-Cohen (Paris, FR)

 

A. Factors affecting duration of first episode:

            1) Central thickness larger than 500 micra.

            2) RPE elevation larger than 50 micra.

            3) Age older than 40 years-old.

B. Recurrences is major problem, rate of recurrence 20-50%.

C. Trigger factors of recurrence:

            1) Irregular RPE.

            2) Subretinal hyperreflectivity.

            3) History of psychiatric illness.

D. IF recurrence occurs in short interval after first episode, prognosis is worse.

E. Author explained mechanisms of pathogenesis of disease; she defends use of mineralocorticoid inhibitor. In addition, for non-responder of mineralocorticoid inhibitor, she proposed use of topical dexamethasone.

 

 

15. The pharmacokinetics of anti-VEGF agents – Pharmacokinetic study of intravitreal aflibercept in humans with neovascular AMD. Diana Do (Palo Alto, EUA)

 

A. Purpose: to investigate the ocular pharmacokinetics of aflibercept after a single intravitreal injection in humans with neovascular AMD.

B. Five eyes from 5 individuals with new-onset neovascular AMD and no history of vitrectomy surgery were enrolled.

C. At baseline, aqueous humor and blood plasma samples were taken from all participants. Immediately after the samples were obtained, all study eyes received a single intravitreal injection of aflibercept, and this time point was designated as Day 0.

D. Study eyes underwent sampling of aqueous humor and blood plasma at 6 additional study time points: 4 hours after injection and Days 1, 3, 7, 14, and 28.

E. Concentrations of free and bound aflibercept were quantified using enzyme-linked immunosorbent assay.

F. The average of half-life of free aflibercept measured in the aqueous after intravitreal injection was found to be ~ 9 days.

G. Plasma levels of free aflibercept were low to undetectable during the first week following injection, and undetectable in all patients at time points beyond 7 days.

 

 

16. OCT Angiography (OCT-A) in the management of AMD and polypoidal choroidal vasculopathy. Philip Rosenfeld (Miami, EUA) and Elie Motulsky (Miami, EUA)

 

A. OCT-A is a powerful, noninvasive imaging strategy for the diagnosis of macular NV.

B. SS-OCT-A appears to be superior to SD-OCT-A for the visualization of neovascular lesions under the RPE.

C. Different en face imaging strategies and retinal vessel projection artifact removal algorithms have been developed to help facilitate the diagnosis and characterization of macular NV.

D. While the outer retinal to choriocapillaris (ORCC) slab is an ideal screening strategy for determining the presence of NV, more refined segmentation strategies are useful to further locate the NV as being above or below the RPE.

E. Currently, OCT-A has proven very useful in assessing whether macular NV is present, but it remains unclear whether the en face flow images from OCT-A provide any additional value over the OCT structural images when determining retreatment with anti-VEGF therapy.

F. The combination of en face flow and structural images, along with the different segmentation strategies used to visualize macular NV and macular fluid, clearly demonstrate that OCT-A provides multimodal imaging from a single imaging modality, and all these images are provided from a single OCT scan.

G. OCT-A provides structural and flow information from a single volume scan.

H. OCT-A may detect subclinical NV in AMD before exudation occurs.

 

 

17. Update on hemorrhagic occlusive retinal vasculitis after cataract surgery (HOCRV). Dean Eliott (Boston, EUA)

 

A. Histologic and immunophenotyping findings of 2 patients with HOCRV.

B. The disease may not be leukocytoclastic retinal vasculitis, but rather a:

            1) Primary non-granulomatous choroiditis.

            2) With secondary retinal vasculopathy.

            3) With diffuse hemorrhagic necrosis of neurosensory retina.

            4) With intraluminal retina vascular thrombosis.

            5) With diffuse choroidal infiltration of inflammatory cells.

            6) Iris and ciliary body infarction # predominance of CD8+ and CD4+ T

               cells in choroidal infiltrate.

C. The choroiditis is predominantly T-cell driven and a type IV rather than type III drug hypersensitivity.

D. FDA recommends against use of intraocular vancomycin during cataract surgery. http://www.retina-specialist.com/article/as-fda-issues-horv-warning-histology-gains-clarification.

 

 

18. Paraneoplastic retinal conditions. Anita Agarwal (San Francisco, EUA)

 

A. Paraneoplastic disorders

            1) Benign diffuse uveal melanocystic proliferation (BDUMP).

            2) Cancer-associated retinopathy.

            3) Melanoma-associated retinopathy.

            4) Paraneoplastic vitelliform maculopathy.

            5) CRMP5-associated Rod cone degeneration.

B. Cancer-associated retinopathy

            1) Often predates the diagnosis of cancer.

            2) Presents with acute onset of photopsias and rapidly progressive

               night blindness evolving into day and night blindness, difficulty with

               central vision and color vision.

            3) Associated antibodies

                        a) Recoverin (23 kDa)

                        b) Enolase (46 kDa)

                        c) Arrestin (48 kDa)

                        d) Carbonic anhidrase II (CAII, 30 kDa)

                        e) Tubby-like protein 1 (TULP1, 78 kDa)

                        f) Interphotoreceptor retinoid-binding protein (IRBP, 145 kDa)

                        g) Heat shock cognate protein 70 (hsc-70, 70 kDa)

                        h) Photoreceptor cell-specific nuclear receptor (PRN, 41 kDa)

                        i) Photoreceptor cell-specific nuclear receptor (PNR, 41 kDa)

            4) Fundus normal initially; later: retinal pigment epithelial mottling,

               vascular attenuation.

            5) Histology: loss of photoreceptors.

 

 

19. Panel about challenging cases in neovascular AMD – Take home messages

 

A. Redução para intervalo quinzenal: primeira medida se não houver resposta a anti-VEGFs; procurar outros fatores que podem impedir a resposta a anti-VEGF, como tração macular.

B. Uso de latanoprosta causa edema macular; retirar em pacientes com AMD neovascular.

C. CNV tipo 1: quando exsuda, começa com líquido sub-retiniano.

D. Sangramento sub-retiniano pós-CNV: observar, injetar gás, anti-VEGF, TPA ou cirurgia. Principal fator prognóstico é o tempo.

E. Rotura de EPR pode causar sangramento. Anti-VEGF não é causa da rotura.

F. Deixar um pouco de liquido pode ser benéfico para evitar atrofia. “Não dê check-mate na CNV; deixe-a somente em check-perpétuo”.

G. Sinal da dupla-linha próxima do EPR pode significar CNV oculta.

H. Quantidade de VEGF e o local da produção inflencia onde vai estar o líquido sub-retiniano ou intrarretiniano.

I. Cistos intrarretinianos podem indicar prognóstico ruim. Se sumirem, melhor; se persistirem, apesar do tratamento, pode significar fibrose e pior prognóstico.

J. PED fibrovascular costuma responder melhor a aflibercept; motivo ainda incerto, pode ser afinidade ou bloqueio de outros membros da família VEGF-PIGF.

L. Máximo de “treat and extend”: 3 meses. Pelo resto da vida, tratar a cada 3 meses, mesmo sem líquido, ou visitas de controle a cada 4-6 semanas; paciente escolhe.

M. Empresa dos EUA desenvolvendo OCT home monitoring: device semelhante a óculos, não fornece imagem da retina, mas detecta quando espessura da retina aumenta 30 micra.

 

 

20. SD-OCT vs SS-OCT. Jay Duker (Boston, EUA) e Carl Rebhun (Boston, EUA)

 

·         SS-OCT requires narrow linewidth, high-speed, frequency-swept lasers that are very expensive. In general, SS-OCT devices use a longer wavelength than SD-OCT. Both 1000-nm and 1300-nm wavelengths have been utilized.

·         Clinical advantages of SS-OCT: faster acquisition speed, wider scanning range (12-mm to 16-mm scan), possible to image vitreous and choroid well simultaneously, longer wavelength (better ability to penetrate choroid, lens opacity, vitreous debris, pigmented epithelial detachments).

·         Disadvantages of SS-OCT: increased cost of light source, worse signal-to-noise ratio, worse motion artifact.

·         SS-OCT divises

            1) Topcon: DRI (Deep Range Imaging) OCT Triton

                        a) 100.000 A-scan per second

                        b) 1050nm wavelength

                        c) 12mm scan length

                        d) multimodal image: color, red-free, FA, FAF, posterior OCT,

                          anterior OCT, OCT-A

            2) Zeiss; Plex Elite 9000

                        a) 100.000 A-scan per second

                        b) 1060nm wavelength

                        c) 16mm scan length

                        d) montage software

·         SS-OCT has theoretical advantages (increased speed, deeper penetration, better ability to image through opaque media) and disadvantages (worse axial resolution, worse signal-to-noise ratio, and more expensive) compared to SD-OCT.

·         SS-OCT will allow for increased field of view with widefield imaging. In addition, with increased A-scan acquisition speed there will be better resolution of larger scans.

 

 

21. Widefield OCT and OCT-A. Nadia Waheed (Boston, EUA)

 

·         When we increase the scanning area, we can see loss of resolution of the vasculature.

·         To overcome this issue, it’s possible to increase the scanning speed (SS-OCT) or to use smaller scans áreas and do montage with the images.

·         Ultra widefield FA still goes further towards the periphery.

·         Be careful with the images in the periphery because when trying to quantify areas of non-perfusion, it’s possible that you’ll find a much larger area than the real one (mercator cartography). It’s possible to correct this distortion with softwares.

·         This distortion isn’t significant to analyze the macular area, but when go outside macula could be a difference of 12-20% in the lesion that you’re imaging or the area of non-perfusion you’re trying to measure.

·         Most commercially available OCT and OCT-A devices have the ability to provide wide field OCT-A (combination of faster speeds, tracking and the ability to montage).

 

 

22. Subclinical diabetic macular changes revealed by OCT angiography. Richard Rosen (New York, EUA)

 

·         While OCT-A currently doesn’t reveal leakage, it can reveal the full spectrum of microvascular retinopathy in multiple capillary beds and detect the loss of even single capillary segments (microaneurysms, vascular loops, non-perfusion, FAZ erosion, venous beading, neovascularization, overlapping capillary beds).

·         Possible to do quantitative analysis, such as multilayer perfused capillary density mapping and foveal avascular zone size and configuration.

·         Studies showed that the capillary distance in OCT-A larger than 60 micra can point to some degree of oxygen insufficiency.

·         Perfused capillary density maps and averages can be used to scale degree of diabetic retinopathy.

·         Patients with diabetic retinopathy has a decrease in the capillary density map as the disease worsens. But there is a point the natural history of the diabetic retinopathy when this perfused capillary density is actually greater than controls. This happened in the diabetic patient without any sign of diabetic retinopathy (this means that this parameter could be useful biomarker between normal and patients with diabetic retinopathy).

·         Non-invasively detect the earliest lesions of diabetic retinopathy prior to visible hemorrhages and microaneurysms.

·         Current anti-VEGF agents have been shown to slow down and even reverse capillary non-perfusion. Newer agents (Tie-2, VAP-1) specifically designed to reverse early capillary closure are currently in early stages of testing.

 

 

23. Redefining atrophy in the era of OCT and multimodal imaging. Srinivas Sadda (Los Angeles, EUA)

 

·         International panel of experts in imaging, histopathology, reading centers.

·         Cases with longitudinal multimodal imaging to allow determination of the first point at which atrophy became evident.

·         Three end-points: 1. Complete/end-stage atrophy; 2. Incomplete/partial atrophy/ 3. No atrophy but high-risk features.

·         Four new terms were introduced:

            1) Complete RPE + outer retinal atrophy (c-RORA), defined by the

               following (all criteria required):

a)    Presence of hypertransmission of equal or > 250 micra

b)    Presence of a zone of attenuation/disruption of RPE, basal laminar (BL) complex of equal or > 250 micra

c)    Evidence of overlying photoreceptor degeneration whose features include all of the following: outer nuclear layer thinning, external limiting membrane loss, ellipsoid zone/interdigitation zone loss

2) Incomplete RPE + outer retinal atrophy (i-RORA), defined by the following (all criteria required):

            a) Some hypertransmission must be present, but often

               discontinuous

            b) Some irregularity of RPE A} BL complex

            c) Detectable photoreceptor degeneration, signs of which can

               include “wedge”, “subsidence”

            d) Absence of signs of an RPE tear

3) Complete outer retinal atrophy defined by the following (all criteria required):

            a) Continuous loss of ellipsoid zone

            b) Severe thinning of outer retina

            c) Intact RPE band

4) Incomplete outer retinal atrophy defined by the following (all criteria required):

            a) Subretinal drusenoid deposits with detectable elllipsoid zone

            b) Detectable thinning of the outer retina

 

 

24. Disease expression in AMD is correlated with choroidal thickness. Richard Spaide (New York, EUA)

 

·         Later OCT imaging and histopathology both showed pseudodrusen were collections of material under the retina (not under the RPE), called “subretinal drusenoid deposits” (SDD).

·         SDD were found to be associated with thin choroids, while soft drusen were associated with normal-thickness choroids.

·         Pachydrusen: generally greater than 63 micra in diameter, are irregular in shape, have a sharply defined border, and are scattered across the posterior pole.

·         Drusen and pachydrusen are accumulations of extracellular material below the RPE, while pseudodrusen are deposits on top of the RPE.

·         Soft drusen has normal choroidal thicknesses, and pachydrusen are found in eyes with thicker choroids.

·         In asian population, eyes with pachydrusen has higher risk to develop polipoidal choroidopathy.

·         Manifestations of late AMD (CNV type, evolution to geographic atrophy) seems to be related to the extracellular deposits and the thickness of choroid.

·         The presence of SDD is highly associated with the development of outer retinal atrophy, GA, and type 3 neovascularization, an each of these has been, associates with a thinner choroid.

 25.  Proliferative diabetic retinopathy (PDR) surgery. André Gomes (São Paulo, Brasil)

 

·         Main goals in surgery for PDR: clear the media, remove all fibrotic tissue and potential residual traction, reduce bleeding, avoid new breaks, reattach the retina, perform epiretinal membrane and or internal limiting membrane removal if needed, apply extensive panretinal photocoagulation, choose the appropriate tamponade when necessary.

·         Recent surgical developments: wide selection of wide-angle viewing systems, new light sources, new machines, microincisional vitrectomy surgery with different gauge options, chromovitrectomy era, anti-VEGF, PFC liquids…

·         What to offer our patients? Segmentation/delamination, “The probe only” technique, bimanual maneuvers, 23, 25, 27 gauges…

 

 

26. Phase 2 trial of ciliary neurotrophic factor (CNTF) for macular telangiectasia Type 2. Emily Chew (Bethesda, EUA)

 

O CNTF tem efeito benéfico e diminui a perda de fotorreceptores nos pacientes com telangiectasia macular tipo 2.

Em comparação com os olhos que não foram tratados com CNTF, houve uma estabilização da acuidade visual nos olhos tratados.

 

 

27. Disease expression in AMD is correlated with choroidal thickness. Richard Spaide (New York, EUA)

 

Vasculopatia coroidiana polipoidal apresenta manifestação fenotípica diferente em comparação com DMRI neovascular típica e é comumente encontrada em olhos com espessura de coroide aumentada.

Embora polipoidal e DMRI sejam clinicamente diferentes, ambas as doenças possuem alelos de risco genético semelhantes. Portanto, a diferença na manifestação clínica deve ser dependente de outros fatores, como espessura da coroide e raça do indivíduo. 

 

 

28. Update on cell-based therapies for atrophic maculopathy. Allen Ho (Philadelphia, EUA)

 

Terapia celular, seja células-tronco ou outro tipo de célula, estão sendo estudadas para os casos de DMRI atrófica.

Há 2 tipos de mecanismo de ação para terapia celular: trófico e regenerativo.

As terapias celulares têm sido bem toleradas nos pacientes com DMRI atrófica.

 

 

29. Anti-VEGF monotherapy vs combination therapy with photodynamic therapy for treatment of polypoidal choroidal vasculopathy. Tien Wong (Singapura)

 

Os resultados do EVEREST-2 e do PLANET mostraram que o tratamento apenas com anti-VEGF seja ranibizumabe ou aflibercept ou o tratamento combinado com PDT resultam em melhora da função visual após 1 ano de tratamento..

O tratamento de escolha depende das características individuais do paciente e do acesso ao PDT.

 

 

30. Subclinical diabetic macular changes revealed by OCT Angiography: why it matters. Richard Rosen (New York, EUA)

 

O OCT angiography tem a capacidade de detectar as lesões mais iniciais da retinopatia diabética, como não-perfusão capilar, possiblitando tratamento específico mais precocemente.

 

Os agentes anti-VEGF atuais têm demonstrado diminuir ou mesmo reverter a não-perfusão capilar retiniana.