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
· 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.
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.