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VOLUME 4 - ISSUE 2

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Macula Society 2017 Updates: Polypoidal Choroidal Vasculopathy and Proliferative Diabetic Retinopathy

 

After participating in this activity, the participant will demonstrate the ability to:
  • Evaluate how recent clinical research into anti-VEGF agents informs treatment for proliferative diabetic retinopathy.
  • Discuss innovations in retina imaging, such as OCT or fundus autofluorescence that can improve diagnosis and treatment of retinal disease.

Guest Faculty Disclosure
Dr. Susan Bressler has disclosed that she has served as a principal investigator for Boehringer Ingelheim Vetmedica GmbH, Notal Vision Inc., and DRCR.net, and has served as co-investigator for Bayer and Novartis AG.

Dr. Gemmy Cheung has disclosed that she has served as a principal investigator for Bayer Corporation, Novartis AG, and Topcon.  She has also served as a speaker for Allergan.
 

Unlabeled/Unapproved Uses
Dr. Bressler and Dr. Cheung have indicated that there will be no references to the unlabeled or unapproved uses of drugs or products in their discussion.
 

 

MEET THE AUTHORS

 

 

 

 

Gemmy Cheung, MD
Deputy Head of the Medical Retina department Clinical Director for Ophthalmic Imaging
Singapore National Eye Centre
Singapore

Susan Bressler, MD
Professor of Ophthalmology
Johns Hopkins University School of Medicine
Baltimore, Maryland

 

 


Release Date: Expiration Date:
August 18, 2017 August 17, 2019

 

 


10 Highlights from the Macula Society Meeting – 2017

1. Limitations of OCT-Angiography in AMD with Vascularized PED.
Salomon Cohen, Sandrine Tabary, Sarah Mrejen-Uretsky

Session II Neovascular AMD I: Wednesday, June 7, 2017; 5:41 PM

eOphthalmology Summary: In an observational study, 25 consecutive patients (6 males, 19 females, age range from 63 to 93 years) with either treatment-naïve or anti-VEGF treated vascularized pigment epithelial detachment (PED) with heights ranging from 268 to 1188 µm, mean: 476 µm, were evaluated by two senior retina specialists using either automated segmentation or manual segmentation of optical coherence tomography angiography (OCTA) images. Cases were included if fluorescein angiography documented the presence of a vascularized PED, and if structural OCT showed both a PED with a height>250 µm as well as either intraretinal fluid, subretinal fluid, or both. The detection rate of choroidal neovascularization for the first reader using automated slabs obtained from OCTA was 11 (44%) of 25 eyes, vs 19 (72%) of 25 eyes by the second reader using manually performed segmentations to review OCTA images. These results seem to be in contrast with the literature of OCTA in neovascular AMD, in which all subtypes of choroidal neovascularization were identified with a detection rate ranging from 85% to 100% of cases. These findings suggest that OCTA is less efficient in vascularized PED compared with other subtypes of choroidal neovascularization, for directly visualizing the abnormal vascular flow that corresponds to type 1 CNV. The results also suggest that automated slabs of OCTA images should be interpreted with caution for diagnosing vascularized PED and that manual segmentations may improve the rate of detection of abnormal blood flow of CNV.

2. Acute Pseudophakic Cystoid Macular Edema Imaged by Optical Coherence Tomography Angiography.
Alain Gaudric, Sophie Bonnin, Aude Couturier, Lise Dubois, Ramin Tadayoni

Session V Vein Occlusion/Uveitis: Thursday, June 8, 2017 11:31 AM

eOphthalmology Summary: To study macular capillary changes and vessel density in acute pseudophakic cystoid macular edema (CME), a retrospective case-control study evaluated 8 eyes (7 patients) with pseudophakic CME and age-matched control eyes using optical coherence tomography angiography (OCTA) (RTVue XR Avanti; Optovue, Fremont, CA, USA). Vessel density of the superficial capillary plexus (SCP) and deep capillary plexus (DCP) were calculated using an updated version of AngioAnalytic software including the Projection Artifact Removal function. The mean time of pseudophakic CME diagnosis was 2.3 ± 0.9 months after surgery. At the first examination, the vessel pattern was normal in the SCP and attenuated in the DCP. Mean vessel density of the SCP was 47.8 ± 3.8% in the study eyes, vs 52.9 ± 4.0% in the control eyes (P=.01), the difference was greater in the DCP layer (44.1 ± 7.4% vs. 54.2 ± 3.2%, P=.007). After resolution of the edema, the vessel pattern in the DCP recovered to normal and the vessel density in both plexuses was no longer different from that of the control eyes. The complete resolution of abnormal vessel patterns and density in acute pseudophakic CME highlights its potentially different pathophysiology from eyes with chronic vaso-occlusive diseases such as diabetic retinopathy or retinal vein occlusion.
Accepted for publication in RETINA

3. Lesion Shape as a Risk Factor for Progression of Geographic Atrophy Secondary to Age-Related Macular Degeneration.
Frank Holz, Maximilian Pfau, Monika Fleckenstein, Moritz Lindner, Lukas Goerdt, Srinivas Sadda, Matthais Schmid, Christopher Brittain, Erin Henry, Daniela Ferrara, Steffen Schmitz-Valckenberg

Session III Dry AMD: Thursday, June 8, 2017 8:24 AM

eOphthalmology Summary: To compare the prognostic value of lesion shape features with growth of geographic atrophy (GA) in age-related macular degeneration (AMD), the authors performed a longitudinal natural history study in 296 eyes of 201 patients with AMD that had GA. Baseline variables, including lesion area, perimeter and the Feret diameters (defined as the distance between the two parallel planes restricting the object perpendicular to that direction) on fundus autofluorescence (FAF) images were graded and evaluated for prediction of the square root lesion growth rate. The two-year results indicated that a single individual factor (i.e., square-root circularity) could explain up to 21% of the variability in growth rates and previous progression rates can explain 18.5% of the variability in upcoming progression rates. In this scenario, the models with square-root circularity (R2=0.379), square-root perimeter (R2=0.344), FAF pattern (R2=0.325), and focality (R2=0.335) were even more accurate in predicting growth rates. The findings herein confirm the potential importance of lesion shape as a prognostic variable for GA growth rates in addition to baseline lesion size, lesion location, multifocality, and fellow eye status.

4. Deep learning in the management of age-related macular degeneration.
Ursula Schmidt-Erfurth, Sebastian Waldstein, Hrvoje Bogunovic , Ferdinand Schlanitz, Georg Langs

Session IV Imaging: Thursday, June 8, 2017 9:33 AM

eOphthalmology Summary: Introducing deep learning, the authors reported the validation of automated computer algorithms for detection and quantification of potential morphologic biomarkers from a cross-sectional analysis of eyes with AMD, based on phenotyped data sets from 317 eyes with the intermediate stage of AMD, 317 with choroidal neovascularization (CNV), and 80 eyes with geographic atrophy (GA). Their results indicated that focal regression of drusen was associated with conversion to advanced AMD with 0.70/0.73 specificity/sensitivity. Disseminated hyperreflective foci in the outer retinal layer were indicative for progression to GA with 80% accuracy, while retinal layer alteration and focal hyperreflective foci over drusen were predictive of CNV development with 66% accuracy. In cases of advanced neovascular AMD, only intraretinal fluid had a moderate impact on functional outcomes and a 70% specificity and sensitivity could be achieved in predicting the retreatment need over 24 months. This study shows that comprehensive analysis of imaging biomarkers using deep learning methods may allow one to reliably estimate disease worsening and treatment response.

5. Efficacy and safety of ranibizumab versus verteporfin photodynamic therapy in Asian patients with myopic choroidal neovascularization: 12-month results from BRILLIANCE.
Timothy Lai, Youxin Chen, Arthur Foo, Renxin Lin, Anna Egger

Session VI Other Macular Diseases: Friday, June 9, 2017 8:41 AM

eOphthalmology Summary: The 12-month outcomes of the BRILLANCE study, which compared the efficacy and safety of ranibizumab 0.5mg versus verteporfin photodynamic therapy in Asian patients with myopic choroidal neovascularization, was reported. 457 patients were randomized 2:2:1 into Group (G) 1 (ranibizumab on day 1, Month 1 and thereafter as needed); G2 (ranibizumab on day 1 and thereafter as needed); or G3 (vPDT on day 1 and treated with ranibizumab or vPDT or both as needed from Month 3). Ranibizumab treatment in G1 (+9.5 letters) and G2 (+9.8 letters) was superior to vPDT +4.5 letters) with differences of G1-G3 = 5 letters (P<.001) and G2-G3 = 5.3 letters (P<.001) based on the mean average BCVA change from baseline to Month 1 through Month 3. The mean BCVA letter change from baseline at Month 12 was 12.0 (G1), 13.1 (G2) and 10.3 (G3). Up to Month 11, patients received a mean of 4.6 (G1), 3.9 (G2) and 2.6 (G3) ranibizumab injections. The results support the use of ranibizumab treatment, with re-treatment guided by visual stabilization or disease activity, over vPDT in Asian patients with myopic CNV at least up to Month 3.

6. Trends and Factors Associated with Diabetic Retinopathy Self-Awareness and Timeliness of Diabetic Eye Care over 6 Years.
Lloyd Aiello, Paolo Antonio Silva, Jerry Cavallerano, Jennifer Sun

Session VII Diabetic Retinopathy I: Friday, June 9, 2017 9:43 AM

eOphthalmology Summary: This study evaluated the extent of, and factors associated with, diabetic retinopathy (DR) self-awareness and timeliness of eye care follow-up over a 6-year period among 12,058 subjects with varying levels of ophthalmic provider specialization. Overall, DR awareness was associated with longer diabetes duration, vision-threatening DR, eye examination within 1 year, prior dilation, scheduled follow-up appointment and greater provider specialization. There was improved DR awareness and timeliness of follow-up during the 6-year period. However, a large proportion of unawareness and timeliness still existed when vision-threatening DR was present in this population, with 52% unaware that they had any DR and 88% not planning timely follow-up eye care relatively to having vision-threatening DR. Although rates appeared to be related to provider specialization, the discrepancy existed across all provider types (44%-87% unaware, 69%-93% not timely), suggesting that methods to enhance transfer and retention of eye care knowledge to diabetic patients are urgently needed.

7. Predictability of IOP Response in Patients Receiving Prior Steroid and Subsequent Administration of the 0.2 ug/day Fluocinolone Acetonide Intravitreal Implant.
Seenu Hariprasad, Clare Bailey

Session VIII Diabetic Retinopathy II: 10:34 AM Friday, June 9, 2017

eOphthalmology Summary: To assess the intraocular pressure (IOP) outcomes following fluocinolone implant (Iluvien®) therapy in eyes previously treated with an intravitreal corticosteroid, 345 eyes (from 305 patients) with DME having a mean follow-up of 428 days were identified by searching electronic medical records across 14 UK sites using the MedisoftTM audit tool of the U.K. EMR systems. After treatment with a fluocinolone implant, for those patients with no history of an IOP-related event after receiving corticosteroid, there were no cases of IOP>30 mmHg nor initiation of IOP-lowering medications. For those patients where an IOP elevation was observed following prior receipt of intravitreal corticosteroids, there was a greater incidence of IOP elevation or use of IOP-lowering medications. This predictability may provide an important clinical tool to mitigate the most common side effect associated with the use of the Fluocinolone Implant in the treatment of pseudophakic eyes with DME.

8. Preliminary Intravitreal Gene Therapy Safety Results for X-Linked Retinoschisis.
Mark Pennesi, Maria Parker, Paul Yang, David Birch, Jason Comander, Anthony Moore, Rabia Ozden

Session XI Tumors/Inherited Retinal Disorders: Saturday, June 10, 2017 8:17 AM

eOphthalmology Summary: In a safety report of intravitreal delivery of rAAV2tYF-CB-hRS1 for gene therapy in x-linked retinoschisis (XLRS), eleven patients, aged from 19 to 80 years old, with XLRS were enrolled in a Phase I/II dose escalation study. Group 1a and 1b subjects who received a dosage of 1 x 1011 vg/eye by intravitreal injection have completed at least 12 months of follow-up. Follow-up in Groups 2 (3 x 1011 vg/eye) and Groups 3 (6 x 1011 vg/eye) patients ranged from 1-11 months. There was no evidence of toxicity based on visual acuity measurements, perimetry, or ERG’s, suggesting that intravitreal treatment with rAAV2tF-CB-hRS1 is well tolerated. Systemic laboratory studies did not identify any clinically meaningful abnormalities. The most common adverse ocular event was intraocular inflammation (anterior and posterior), which ranged from mild to moderate, and was controlled or resolved with or without the use of topical and/or oral corticosteroid treatment.

9. HDL-Cholesterol as Causal Risk Factor for Age-Related Macular Degeneration.
Tien Wong, Qiao Fan, Joseph C. Maranville, Caroline Chee, Runz Heiko, Ching-Yu Cheng

Session XIII Neovascular AMD II: 10:58 AM Saturday, June 10, 2017

eOphthalmology Summary: To investigate the potential role of plasma lipid levels in late AMD across multiethnic populations, the team selected 185 single nucleotide polymorphisms (SNPs) as instrumental variables associated with plasma lipids to evaluate 16,144 late AMD cases and 17,832 controls of European descent, together with 2,219 cases and 5,275 controls of Asian descent using a two-sample Mendelian randomization approach. They found that higher plasma HDL cholesterol was associated with an increased risk of late AMD in both Europeans and Asians, after accounting for pleiotropic effects with LDL cholesterol and triglycerides. Conversely, neither LDL cholesterol, nor triglyceride levels were associated with AMD. The study implicates HDL as a key factor in development of late AMD.

10. Augmented Reality Video Microscope (ARVM) for Retina Surgery as a Replacement of Operational Microscopes.
Anat Loewenstein, Amir Manor, Adiel Barak

Session XIV Vitreoretinal Surgery: Saturday, June 10, 2017 11:36 AM

eOphthalmology Summary: To test the augmented reality video microscope (ARVM) imaging quality and its impact on surgery visualization and to test intra-operative surgical assisting applications for improved surgery decision making, 5 patients for extraction of silicone oil from the vitreous cavity were studied in the primary part of the examination and during the surgery. The system's key parameters were refined to enhance performance related to surgery visualization, ergonomic and setup time. Related patient OCT data was displayed to the surgeon in real time in correspondence to the retina visualization produced from the ARVM. Results suggested good visualization of the posterior chamber was achieved using the ARVM. Digital image manipulation allowed control of image rotation, light parameters, digital zooming and image enhancement for optimal visualization of both the retina and vitreous cavity. The set-up time at the beginning of surgery was short and the adjustment of the head wearable display (HWD) was seemed relatively easy. The surgeon reported that the HWD did not impose any fatigue or stress on the head, and was judged to be comfortable by all participants. The use of this HWD, the ultra-resolution stereoscopic cameras and computerized processing has the potential of improving the surgeon's images, enables supporting information to be visualized during surgery, and may enhance surgical performance.

 

 

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PROGRAM DIRECTOR
PROGRAM PLANNER

Neil Bressler, MD
James P. Gills Professor of Ophthalmology Chief of the Retina Division
Wilmer Eye Institute at Johns Hopkins
Baltimore, Maryland

Jun Kong, MD, PhD
Post-Doctoral Clinical Research Fellow
Wilmer Eye Institute Johns Hopkins Hospital
Baltimore, Maryland

 

 

 

 

CME/CE INFORMATION

 

 

ACCREDITATION STATEMENT
Physicians
This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the Johns Hopkins University School of Medicine. The Johns Hopkins University School of Medicine is accredited by the ACCME to provide continuing medical education for physicians.

CREDIT DESIGNATION STATEMENT
Physicians
The Johns Hopkins University School of Medicine designates this enduring material for a maximum of 0.5 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

 

POLICY ON SPEAKER AND PROVIDER DISCLOSURE
It is the policy of the Johns Hopkins University School of Medicine and the Institute for Johns Hopkins Nursing that the speaker and provider globally disclose conflicts of interest. The Johns Hopkins University School of Medicine OCME has established policies in place that will identify and resolve all conflicts of interest prior to this educational activity. Detailed disclosure will be made in the instructional materials.

 

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DISCLAIMER STATEMENT

STATEMENT OF RESPONSIBILITY

STATEMENT OF NEED
INTENDED AUDIENCE

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HARDWARE & SOFTWARE REQUIREMENTS

COMPLETE CME INFORMATION

 

 

 

All rights reserved - The Johns Hopkins University School of Medicine. Copyright 2017.

This activity was developed in collaboration with DKBmed.