Download December 9. 2016

APVRSSHOWDAILY
December 8-10, 2016
Bangkok, Thailand
The Official Conference News of APVRS 2016
Highlights
4
Get the latest ‘tips and
tricks” in managing
uveitis
7
10
Day
2
Ancient Thai Culture
10th APVRS Opening Ceremony
Offers a Taste of
Imaging and therapy
of choroidal tumors
have come a long way
Enjoy more updates in
retinal surgery
by John McMahon
B
Published by:
Editorial Team
Creative Content Director
Matt Young
Chief Editor
Gloria D. Gamat
Project Manager
Ruchi Mahajan Ranga
Writers
John McMahon
Kaylen Moore
Designer
Winson Chua
Photographer
Dwayne Foong
Media MICE Pte. Ltd.
6001 Beach Road, #19-06
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www.mediaMICE.com
angkok, a city famous for its exquisite
food, exotic sites, and unique traditions
welcomes the 10th annual congress of the Asia
Pacific Vitreo-retina Society (APVRS 2016). This
year’s congress held in conjunction with the
38th Annual Meeting of the Royal College of
Ophthalmologists of Thailand (RCOPT) comes
together at the Bangkok Convention Center
from December 8 through 10. Marking a decade
in existence, APVRS 2016 brings together over
200 invited regional and international speakers
sourced from 20 countries addressing a range of
current challenges and leading practices in the
vitreoretina subspecialty.
The ceremony opened with a taste of ancient
Thai culture featuring a traditional drumming
group of four young men dressed in traditional
costumes playing a partially syncopated rhythm
while chanting. Shortly they were accompanied
by four women in lavish pink and green Lacoon
outfits who performed a slow, elegant dance in
front of the giant digital screen emblazoned with
the 10th annual APVRS congress logo.
APVRS Congress President, Dr. Paisan
Ruamviboonsuk, opened the ceremony by
welcoming everyone to the city of angels. He
outlined the itinerary that will cover a broad
range of subjects in medical and surgical
vitreoretinal pathology, including macular
degeneration, diabetic eye disease, macular
surgery, uveitis, oncology, and pediatric retinal
disorders. He talked about the opportunities
that modern Bangkok offers visitors and invited
all participants to enjoy the city during one of
the nicest weather of the year. He suggested
visiting the royal palace, or taking a river cruise
and then made a joke about how many had
already left to do some sightseeing.
Cont. on Page 9 >>
PhotooftheDay
Worawit, a
product specialist
with Filtech
Enterprise,
shows off...and
also shows off
the Optomed
Smartscope PRO
non-mydriatic
digital fundus
camera
1
Abbreviation of Eylea Product Information:
Presentation; 1 ml. solution for intravitreal injection contains 40 mg aflibercept Indication: for treatment of neovascular (wet) age-related macular degeneration (wet AMD), macular edema secondary to central retinal vein occlusion (CRVO), diabetic macular
edema (DME), macular edema secondary to branch retinal vein occlusion (BRVO), myopic choroidal neovascularization (myopic CNV). Dosage and method of administration: For Neovascular (wet) age-related macular degeneration (wet AMD), the
recommended dose for Eylea is 2 mg (equivalent to 50 microliters) intravitreal injection. EYLEA treatment is initiated with one injection per month for three consecutive doses, followed by one injection every 2 months. For Macular edema secondary to central retinal
vein occlusion (CRVO), the recommended dose for EYLEA is 2 mg. After the initial injection, treatment is given monthly until visual and anatomic outcomes are stable for three monthly assessments. For Diabetic macular edema (DME), the recommended dose for
EYLEA is 2 mg administered by intravitreal injection monthly for the first 5 consecutive doses, followed by one injection every 2 months. Macular edema secondary to branch retinal vein occlusion (BRVO), the recommended dose for Eylea is 2 mg. After the initial
injection, treatment is given monthly. For Myopic choroidal neovascularization (myopic CNV), the recommended dose for EYLEA is a single intravitreal injection of 2 mg. Additional doses should be administered only if visual and anatomic outcomes indicate that
the disease persists. Contraindications: Ocular or periocular infection, Active severe intraocular inflammation, Known hypersensitivity to aflibercept or to any of the excipients. Special warnings and precautions for use; Intravitreal injections including those with
EYLEA, have been associated with endophthalmitis, Increase in intraocular pressurehave been seen within 60 minutes of an intravitreal injection, Women of childbearing potential should use effective contraception during treatment. Adverse reactions: Very
common (≥1/10 patients) Conjunctival hemorrhage, Eye pain Selected adverse reactions: Arterial thromboembolic events (ATEs) are adverse events potentially related to systemic VEGF inhibition. There is a theoretical risk of ATEs following intravitreal use of VEGF
inhibitors. Immunogenicity-as with all therapeutic proteins, there is a potential for immunogenicity with EYLEA. Incompatibilities: EYLEA must not be mixed with other medicinal products
โปรดอานรายละเอียดเพิ่มเติมในเอกสารกำกับยา
ใบอนุญาตโฆษณาเลขที่ ฆศ. 726/2559
APVRSSHOWDAILY | December 8-10, 2016 | Bangkok, Thailand
Treatment Options in Pathologic Myopia
by Kaylen Moore
K
icking off the Medical and Surgical
Management of Pathologic Myopia
symposium , international experts
discussed treatment options of pathologic
myopia.
With a unique and diverse population, a
Singaporean study shared by Dr. Gemmy
Cheung, MBBS(Lond), FRCOphth(UK),
Senior Consultant, Ocular Inflammation
and Immunology Department, Singapore
National Eye Centre, highlighted the
ethnic differences in myopia indications.
Compared to Indian and Malay populations,
Chinese patients display a higher
occurrence of myopia. Globally, myopia
impacts about 40% of both Chinese and
Japanese patients, yet only 15% to 20% in
those who are ethnically European.
Worldwide the prevalence of myopia is
increasing across ethnicities, and more
people are experiencing moderate and
high levels of myopia when compared
to studies from the 1960s. It is one of the
leading causes of blindness and visual
impairment globally.
Further research will need to be
completed to determine the relationship
between school myopia and pathologic
myopia, to see if interventions at an early
period will translate into reduction in
pathologic myopia and related blindness.
In another presentation, Dr. Danny
Ng, BSc(JHU), MBBS(HKU), MPH (HKU),
FRCS(Edin), FCOphth (HK), FHKAM
(Ophth), Assistant Professor, Department
of Ophthalmology & Visual Sciences,
The Chinese University of Hong Kong,
discussed OCT use for subretinal
hyperreflective material (SHRM). In his
presented study, 58 eyes of 50 patients
with pathologic myopia and SHRM,
including: active myopic CNV, quiescent
myopic CNV with scar, and submacular
hemorrhage without CNV.
The sensitivity of OCTA for detecting myopic
CNV was 63.3% in quiescent eyes, which was
lower than the 94.1% in eyes with active CNV.
Additionally, OCTA can detect chorioretinal
atrophy adjacent to CNV similarly to FA and
ICGA. OCTA in the future may be useful as a
first screening to non-invasively differentiate
submacular hemorrhage from myopic CNV.
Dr. Kenneth Fong
Myopic CNV may occur at any degree of
myopia, and even in eyes without any
typical myopic degenerative fundus
changes, noted Dr. Lihteh W, M.D.,
University of Costa Rica. Symptoms such
as visual acuity decreases, scotoma, and
metamorphopsia require multimodality
for a strong diagnosis and OCT scan is
not enough to determine if a patient is
suffering from CNV.
Laser photocoagulation treatment has
been shown to lead to scar expansion and
atrophy, without long-term visual acuity
gains, and patients show a high rate of
recurrence. In a prospective pilot study of
intravitreal bevacizurnab for myopic CNV,
32 eyes we followed with mean follow-up
time of 24 months. These patients showed
significant improvement of BCVA (30-45
letters), and 47% of eyes received only the
loading dose.
The efficacy shown between the two
modalities discussed was quite consistent;
and focus should be paid in the future
to early treatment of RNZ as crucial to
prevent irreversible retinal damage, and
with earlier treatment less injections are
required.
Dr. Kenneth Fong, MA MB BChir
(Cambridge), FRCOphth (UK), FRANZCO
(Aust), CCT (UK), AM (Mal), Sunway Medical
Centre, Selangor, Malaysia, took the stage
to present about dome shaped macula
(DSM), its incidence, pathogenesis and
diagnosis, and implications for treatment.
It is typically an “inward bulge inside the
chorioretinal posterior concavity of the
eye, in macula” and found in 20% of highly
myopic patients (of 1,118), with foveal
detachment occurring in 70% of eyes with
symptomatic vision loss.
Surgical treatment of myopic foveoschisis
in high myopia was presented by Dr. Ian
Wong, MBBS(HKU), M.Med (Singapore),
FCOphthHK, FHKAM (Oph), FRCS
(Edinburgh), FRCOphth, S8 Eye Clinic,
Queen Mary Hospital, Hong Kong,
with a focus on the lack of elasticity of
the internal limiting membrane (ILM).
Current treatment is mainly vitrectomy,
ILM peeling and gas injection. However,
postoperative records show that full
thickness macular hole formation has
occurred in 13% to 28% of cases, meaning
potential harm to almost one-quarter of
patients.
To avoid trauma to the retina, modified
ILM peeling spares the fovea by centripetal
lifting and careful trimming to leave
behind a small, circular area (~500um) of
the ILM over the fovea untouched. This
modified technique is promising, even
over the small case series performed so far,
and is able to be done without additional
equipment or consumables compared to
current methods.
Dr. Akito Hirakata, M.D., Professor,
Department of Ophthalmology, Faculty of
Medicine, Kyorin University, Mitaka, Japan,
concluded his presentation highlighting
that scleral shortening and vitrectomy
with induction of PVD and/or ILM peeling
could be useful to treat myopic traction
maculopathy to prevent macular hole
(MH) development, and a secondary toric
IOL implantation may be useful to reduce
surgical induced astigmatism after scleral
shortening.
Closing out the morning session, Dr.
Tzyy-Chang Ho, M.D., attending physician
and clinical associate, Department
of Ophthalmology, National Taiwan
University Hospital, Taiwan, presented a
dye free, noninvasive method for foveal
repairing ILM peeling surgery for myopic
macular hole/retinal detachment. For
repairs of macular hole (MH), or macular
hole retinal detachment (MHRD) in highly
myopic eyes, this C-shaped flap method
significantly reduces the standard prone
time for patients and does not interfere
with any tissue deeper than ILM, with no
intentional drainage of SRF performed.
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APVRSSHOWDAILY | December 8-10, 2016 | Bangkok, Thailand
The Cutting Edge
of Managing Uveitis
vessels. From this, it is possible to create
a measurement for vascular volume that
was previously unknown. Dr. Pichi concurs
with the need for multimodality, as OCTa
does not have the dynamic capabilities
of indocyanine green (ICG) angiography,
but is excited to make the jump from
subjective to objective measurement of
uveitis.
by Kaylen Moore
C
urrent treatment of uveitis is moving
forward, with use of ocular imaging
and laboratory tests including optical
coherence tomography (OCT), wide-field
photo angiography, polymerase chain
reaction (PCR), newly introduced drugs,
and drug delivery systems to go further
than traditional clinical examinations.
Dr. Ann-Marie Lobo, M.D., Assistant
Professor of Ophthalmology and CoDirector, Uveitis Service, University of
Illinois College of Medicine, Chicago,
began the session by asking when it is
appropriate to order tests. Do you need
to rule out infectious processes? Is it an
atypical presentation? Are you looking for
tailored therapy due to drug resistance?
PCR testing can detect organisms which
are difficult to grow in culture, organisms
even with prior antimicrobial therapy,
and organisms sequestered on surfaces of
prosthetic materials in ocular fluid samples.
For viral retinitis (HSV/VZV/CMV), there is a
high sensitivity (82%) and high specificity
(97% to 100%) when using PCR in
diagnosis of infectious posterior uveitis.
Also, Dr. Lobo emphasized the importance
of immediate processing of samples, as
delayed sample processing is a culprit for
false positives.
Using multimodal imaging for uveitis
was the topic for Dr. Hyeong Gon Yu
of Seoul National University Hospital,
South Korea, as he emphasized the
growth of multimodal imaging in all
areas of ophthalmology. He reminded the
audience of how different imaging types
can complement one another, and their
combination of data can be even greater
than the sum of their parts.
With uveitis, multimodal imaging allows for
identifying the pathophysiology through
multilayer involvement of the retina,
retinal pigment epithelium (REPE) and
choroid. Dr. Yu was also excited about the
opportunities coming from ultra-widefield (UWF) imaging, with its allowance
of 200-degree photographic view of the
fundus, which is ideal for evaluating the
peripheral retina at a glance.
Highlighting detailed intraoperative OCT
in uveitis, Dr. Thanapong Somkijrungroj,
Bumrungrad International Hospital,
Thailand, noted that the Rescan 700
(Carl Zeiss Meditec, Jena, Germany)
provides real time HD intraoperative OCT
(iOCT), with the projection directly into
the surgeon’s right eye. Though there
were concerns over additional time this
enhanced procedure would take, overall
surgeons only spent 4.9 minutes longer,
according to results of his study.
Reported in the DISCOVER study, 61%
of surgeons believed that membrane
peeling was complete prior to iOCT
scan, yet of the iOCT scans, 22% actually
revealed residual occult membranes that
the surgeons decided needed additional
peeling. iOCT functions for both anterior
and posterior segment surgery, and can
impact surgeon decision making for
better outcomes.
These technologies can provide better
diagnosis and monitoring for patients,
with faster detection of recurrence and
improvements.
Talking about masquerade syndrome in
uveitis, Dr. Un Chul Park, M.D., New York
Eye and Ear Infirmary of Mount Sinai, New
York, USA, stressed the need for prompt
and correct diagnosis. A 2004-2012 study
shows that 2.5% of patients presenting
with uveitis at the Nationa Eye Institute
(NEI) were suffering from neoplastic
masquerade syndrome. These patients
are more likely to be male, older, nonAfrican American, suffering from unilateral
posterior segment inflammation.
Further, Dr. Francesco Pichi, M.D.,
Cleveland Clinic, Cleveland, USA, focused
his discussion on optical coherence
tomography angiography (OCTa). With
its ability to give information at the deep
capillary layer, OCTa can create a 3-D
rendering of the iris, with isolation of the
The audience was reminded that atypical
features and resistance to conventional
steroid therapy may require further
analysis to reach the correct diagnosis,
while saving the patient’s vision and life.
In addition, diagnostic vitrectomy can
aide in identifying these copycat diseases.
APVRSSHOWDAILY | December 8-10, 2016 | Bangkok, Thailand
Operate with Your Head Up
by Gloria D. Gamat
I
nstead of looking through the eyepiece
of a microscope, the digitally assisted
vitreoretina surgery (DAVS) platform allows
ophthalmologists to see things from a
surgical perspective better than ever before.
At its exhibition booth at the APVRS
Congress 2016 in Bangkok, Thailand,
Alcon welcomed delegates for a handson demonstration of the company’s new
DAVS digital microscopy platform – the
NGENUITY 3D Visualization System.
The MUST Trial (Steroid Implants and
Uveitis) was presented by Professor
Lyndell Lim, MBBS, FRANZCO, Senior
Associate Ophthalmologist, Eye Surgery
Associates, Melbourne, Australia, with
a focus on steroid implants among all
treatments of uveitis. The Multicenter
Uveitis Steroid Treatment (MUST) Trial
followed 255 patients (479 eyes) and was
randomised 1:1 between Retisert steroid
implants (Bausch & Lomb, Rochester,
New York, USA) and standard systemic
immunosuppression. All participants
were presenting uveitis currently, or
recently active (within 60 days).
Unsurprisingly, patients with poor vision
at the baseline had the most visual gains.
The Retisert group lead in visual gains
initially, but the systemic group began
to catch up. At 24 months, both groups
showed various side effects.
After 5 years, virtually 100% of patients
needed cataract surgery and the pellets
have fallen off. However, inflammation
was under better control in the implant
group when compared to the systemic
group for uveitis relief.
Closing the session, Dr. Yu Cheol Kim,
M.D., Keimyung University, South
Korea, discussed posterior uveitis and
highlighted that less invasive pars plana
vitrectomy (PPV) makes a difference.
Vitrectomy can be an indispensible
tool for uveitis, icro-incision vitrectomy
surgery (MIVS) and wide viewing systems
are preferred for high outcomes. For best
outcomes, Dr. Kim emphasized the role
of patient selection, preoperative and
postoperative inflammation control.
The NGENUITY 3D Visualization System
integrates a 3D camera, which is attached
to the operating microscope optics, and
a flat panel, high-definition 4K OLED
monitor. Here, the surgeon can view a 3D,
stereoscopic image of the surgical field
through passive glasses. The bottom line
is that this provides higher magnification,
enhanced depth of field, enhanced
peripheral acuity and improved peripheral
awareness. From now on, you can think
of using a standard surgical microscope
like riding a bicycle and looking at the tire:
While you can see what’s going on, you are
more likely to crash the bike. In using the
NGENUITY 3D Visualization System, you
can look up and be far more aware of the
surgical surroundings.
“The system is excellent and very
interesting,” said Dr. Ik Soo Byon of South
Korea. “It has a very good resolution and
finer 3D visualization that would enable
surgeons to operate well and potentially
may lead to better patient outcomes.”
The ergonomics in this heads-up technique
often delivers the initial ‘wow’ factor to
most surgeons.
“The system is very amazing,” shared Dr.
Zhuping Xu, APVRS 2016 delegate from
China after trying the machine herself.
“Ergonomically, it is better for the surgeons
both in clinical practice and for teaching
purposes. Patient outcomes using this
system would be a lot better.”
Also, the electronic amplification of the
camera’s signal results in increased image
brightness, allowing use of reduced
endoillumination levels.
“
[The system]
has a very good
resolution
and finer 3D
visualization that
would enable
surgeons to
operate well
and potentially may lead to better
patient outcomes.
- Dr. Ik Soo Byon
”
“
Ergonomically,
it is better for the
surgeons both in
clinical practice
and for teaching
purposes.
”
- Dr. Zhuping Xu
The machine can
“provide
clearer
visual field on the
screen compared
to looking
through the
microscope.
- Dr. Yue Qiu
”
“The machine can provide clearer visual
field on the screen compared to looking
through the microscope,” said Dr. Yue Qiu,
a young ophthalmic surgeon from China.
“The 3D is very good, providing an indepth view of the eye.”
Dr. Qui highlighted that the system is
very convenient because it can be paired
and is compatible with other brands of
microscope and OCT.
“More importantly, a low degree of
light can be used while operating,” she
concluded. “This is good for the patient’s
macula and will provide less strain to the
eye of the doctor doing the operation.”
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APVRSSHOWDAILY | December 8-10, 2016 | Bangkok, Thailand
Spotlight on Key Symposium
Intravitreal Sirolimus
A
ny part of the eye can be affected by
uveitis, which can be infectious or noninfectious. In non-infectious uveitis (NIU),
the pathophysiology is often of autoimmune
origin, manifesting secondary to systemic
diseases or due to local conditions.
Inflammation of the uvea and adjacent
structures in NIU is mediated by T cells and
perpetuated by proinflammatory cytokines.
Therefore, treatments for NIU target the
inflammatory pathology. This includes
systemic and local corticosteroids, systemic
immunosuppressants and biologics.
Although systemic corticosteroids are
effective in a majority of patients, its longterm use is associated with a risk of serious
adverse effects.
New therapy on the horizon…
What if NIU can be treated by a localized
immunoregulator? In that case, serious
adverse effects associated with the use of
systemic immunosuppressants would not be
an issue.
Enter intravitreal sirolimus – a local
immunoregulatory therapy for managing
non-infectious uveitis of the posterior
segment (NIU-PS). This novel agent is an
mTOR inhibitor that plays immunoregulatory
role by interrupting T-cell proliferation
driven by interleukin-2 (IL-2) and other
proinflammatory cytokines, with minimal
systemic exposure.
Promising Novel Localized Immunoregulatory Therapy
for Non-Infectious Uveitis of the Posterior Segment
SAKURA Study 1 is the first of two Phase III,
randomized, double-masked, multinational
studies conducted in the European Union,
India, Israel, Japan, Latin America, and the
United States, evaluating the long-term safety
and efficacy of intravitreal sirolimus. The
study’s primary objective is to evaluate the
safety and efficacy of the intravitreal injection
of 440 μg and 880 μg sirolimus versus 44 μg
for the treatment of active NIU-PS.
As part of the SAKURA Study 1, Dr. Alay S.
Banker, M.D., from Banker’s Retina Clinic
and Laser Centre, Ahmedabad, India, and
his team examined the 12-month safety
outcomes of intravitreal sirolimus in Indian
subjects with active NIU-PS. Study findings
demonstrated that overall, a significantly
higher proportion of Indian subjects
receiving the 440 μg dose (31.4%) of
intravitreal sirolimus injections for NIU-PS
achieved a resolution of inflammation (VH
of 0) when compared to those who received
the active control dose of 44 μg (10%).
The investigators highlighted that although
ocular adverse events (AEs) and serious AEs
observed with intravitreal injections of sirolimus
in SAKURA Study 1 were not unexpected, the
incidence rate of ocular serious AEs did not
increase with long-term use.
“The 440 μg intravitreal sirolimus injections may
be an efficacious and safe therapeutic option
for non-infectious uveitis of the posterior
segment,” shared Dr. Banker. “Also, the SAKURA
Study 2 may provide additional data on the
Details of the SAKURA Study 1 findings will be presented at the APVRS Congress
2016 on December 10, 2016 (Saturday), 14:30 – 16:00 hrs, at Lotus 11.
The findings are based on research by the following physicians (and please note their
presentation titles as well):
Dr. Alay S. Banker
Dr. Vishali Gupta
Intravitreal Sirolimus:
Long-Term Safety
Results in Indian
Subjects with
Noninfectious Uveitis
of the Posterior
Segment
24-Month Safety
Outcomes: Treatment
of Noninfectious
Uveitis of the
Posterior Segment
with Intravitreal
Sirolimus
For more information, please contact: Dr Femmy Yunia Bahroen at [email protected]
This symposium preview has been supported by an educational grant from Santen.
References:
Mudumba S, Bezwada P, Takanaga H, et al. Tolerability and pharmacokinetics of intravitreal sirolimus. J Ocul Pharmacol
Ther. 2012;28(5):507-514.
Nguyen QD, Merrill PT, Clark WL, Banker AS, et al.; Sirolimus study Assessing double-masKed Uveitis tReAtment
(SAKURA) Study Group. Intravitreal Sirolimus for Noninfectious Uveitis: A Phase III Sirolimus Study Assessing DoublemasKed Uveitis TReAtment (SAKURA). Ophthalmology. 2016;123(11):2413-2423.
benefit/risk profile of intravitreal sirolimus for
the treatment of NIU-PS,” he added.
In a similar study, Dr. Vishali Gupta, M.D.,
from Advanced Eye Centre, Post Graduate
Institute of Medical Education and Research,
Chandigarh, India, and her team evaluated
the 24-month safety outcomes of intravitreal
sirolimus for the treatment of active NIU-PS.
The investigators found that the most
efficacious dose of 440µg was observed to
be safe and tolerable over the 24-month
study period. More importantly, the
systemic exposure to sirolimus fell below
the immunoregulation threshold and no
clinically relevant systemic safety issues were
reported in subject patients.
“A major issue in NIU is that it keeps coming
back. To prevent recurrences, a form of
immunoregulator therapy needs to be
administered,” said Dr. Gupta.
“But the problem with treatment is that it
comes with a lot of systemic side effects. In
NIU-PS, the disease is local in the eye, and a
local immunoregulator is the ideal treatment
scenario,” she explained.
“Uveitis is a potentially blinding disease, and
we don’t have a better alternative to systemic
immunoregulator at the moment. Intravitreal
sirolimus will allow treatment of the condition
in a localized manner (without the systemic
side effects) and I’m so looking forward to it,”
she concluded.
APVRSSHOWDAILY | December 8-10, 2016 | Bangkok, Thailand
Choroidal Tumors:
Improvements in Imaging and Therapy
different types of uveal metastasis and
similar lesions were presented to highlight
diagnostic issues often encountered by
doctors.
by John McMahon
T
he APVRS 2016 session on
improvement in imaging and therapy
of choroidal tumors began with a brief
history of common choroidal tumors,
which was presented by Dr. Santosh
Honavar, MD (AIIMS), FACS, Director
of Medical Services, Centers for Sight,
Hyderabad India, in which he summarized
the progress in diagnostic technique
and treatment of uveal melanoma. Dr.
Honavar showed slides illustrating the
commonalities of occurrence in certain
populations before beginning the
discussion of racial differences in tumor
rates – that would continue as a theme
for most speakers. They pointed out
however, that the occurrence among
Caucasian patients far outweighs that of
Asians.
The second speaker, Dr. Evangelos
Gragoudas, M.D., Director, Retina Service,
Massachussets Eye & Ear, Harvard Medical
School, presented a 40-year history
of the use of proton beam irradiation
as treatment for uveal melanoma. Dr.
Gragoudas highlighted that before
proton beam irradiation, the standard
for treating uveal melanoma was removal
of the eye (enucleation). Following the
discussion was a brief description of the
development of proton beam therapy,
it’s side effects and benefits. He looked
to a multidisciplinary approach in the
future of pairing with a combination of
radiation and antiangiogenic agents to
decrease the amount of cytotoxic effects
of radiation on normal tissue.
Furthermore, Dr. Hiroshi Goto, M.D.,
Department of Ophthalmology, Tokyo
Medical University, Japan, delivered
the efficacy of specific scintigraphy for
the diagnosis of uveal melonoma. He
discussed a study of 99 patients where
single-photon emission computed
tomography (SPECT) images were
obtained after the intravenous injection of
N-isopropyl iodoamphetamine. The study
concluded that intravenous injection of
N-isopropyl iodoamphetamine is useful
for the diagnosis of malignant uveal
melanoma as well as a measured step
against misdiagnosis.
Talking about choroidal melanoma,
Dr. An-Ning Chao returned to the
topic of the racial difference in rates of
developing choroidal melanoma. Dr. Chao
emphasized that choroidal melanoma is
the most primary intraocular malignancy
in adults and discussed the usefulness of
the American Joint Committee on Cancers
Classification of Tumors in staging the
condition (i.e. categories T1-T4). Dr. Chao
concluded her presentation with slides
illustrating the size categories of tumors,
differential diagnosis of pigmentation
and the clinical features of choroidal
melanoma.
On the other hand, Dr. Duangnate
Rojanaporn’s lecture on lesions that can
simulate choroidal melanoma focused
on the issue of diagnostic difficulties.
Using the mnemonic device, “to find
small ocular melanoma, using helpful
hints daily”, recognizes thickness, fluid,
size, orange pigment, ultrasound,
halo and density as the key indicators
to differentiate between lesions and
melanoma. Slides and video examples of
The role of genetic testing for uveal
melanoma was presented by Dr. Minoru
Futura, M.D., Fukushima Medical
University, Japan. The breakdown of the
prognostic risk factors, as highlighted
by Dr. Futura, includes basal diameter,
macular thickness, extrascleral extension,
epitheloid histology and mitotic rate. Dr.
Futura went on to discuss a small study
involving only 6 patients in Fukushima,
Japan, as being inconclusive. “Genetic
testing has come of age because of
its ability to predict the likelihood of
developing uveal melanoma and perhaps
more importantly for the peace of mind of
patients,” he said.
Finally, Dr. Jerry Shields, M.D., a
distinguished ocular oncology expert
at Wills Eye Hospital, Philadelphia,
ran through a brief history of uveal
melanoma’s diagnostic and treatment
changes. Starting with radioactive
injections from the 1970’s to current
practices, including a thorough discussion
of simply observing the growth of tumors.
Additionally, Dr. Carol Shields, M.D.,
from the Wills Eye Hospital, discussed
the scenario of the future of melanoma
management by presenting the newest
practices of light therapy, targeted drugs,
vascularization blockade, and then
continued to describe T-cell training.
Dr. Shields ended the session with an
anecdote about former U.S. President
Jimmy Carter receiving T-cell training
treatment with the result of complete
remission from brain cancer.
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APVRSSHOWDAILY | December 8-10, 2016 | Bangkok, Thailand
Managing Complications of
Anterior Segment Surgery
With on-going technical trouble and
the power presentation coming in and
out, Dr. Doric Wong, Singapore National
Eye Centre, presented on ‘Anterior
Segment Surgery in the Presence of
Retinal Pathology’ focused on diabetic
retinopathy’s ICO guidelines for diabetic
eye care. This led to the pro’s and con’s
of surgery and drug treatment. He
concluded with the connection between
age related macular degeneration and its
relation to cataract surgery.
by John McMahon
T
he session on managing complications
of anterior segment surgery featured
experts who shared their techniques to
address issues such as posterior capsular
rupture and vitreous loss, intraocular lens
dislocation and management, iris trauma
and repair options, complications of
glaucoma surgery and its management,
intraocular surgery in the context
of preexisting retinal pathologies,
current management of postoperative
endophthalmitis, and advanced corneal
vitreoretinal surgery in the context of
corneal opacities.
Dr. Pakitti Tayanithi, M.D., associate
professor, Bumrungrad International
Hospital, Bangkok Thailand, started off
with ‘Complicated Cataract Surgery—
Tips and Tricks in Managing Posterior
Capsule Rupture’ by listing the three key
factors for preparing for capsular rupture:
recognize, stop, stabilize it. While a good
surgeon can avoid a rupture more than
90% of the time, one should always be
prepared, emphasized Dr. Tayanithi, and
concluded his presentation with a series
of precautions to avoid grasping vitreous.
Dr. Sze Guan Ong, M.D., founding partner
and senior consultant ophthalmic surgeon
at Eye & Retina Surgeons, Camden
Medical Centre, Singapore, discussed the
complicated topic of ‘Cataract Surgery—
Current Evidence and Management of
Dislocation/ Subluxation of Lens and
intraocular lens (IOL)’. It was a point by
point break down of lens removal, IOL
dislocation followed by options and
choices of IOL techniques. Comparing
scleral suture with sutureless procedures
and weighed the disadvantages and
benefits of each.
On the other hand, Dr. Tjahjono
Gondhowiardjo, Jakarta Eye Center,
Indonesia, began his presentation with
serious technical difficulties, but once
the problems were straightened out he
discussed ‘Iris Trauma/Iris Loss—Suture
Techniques and Artificial Iris Options and
touched on the subjects of iris suturing,
iridodialysis reconstruction and showed a
video featuring different iridia devices. He
closed with a comparison of artificial iridia
versus sceleral IOL.
Dr. Boonsong Wanichwecharungruang,
M.D., Bumrungrad International
Hospital, Bangkok Thailand, came to the
podium next with ‘Posterior Segment
Complications of Glaucoma Surgery
and Cyclodialysis’. He started with a
comparison of treatments, specifically,
drug therapy or surgery, noting that 50%
of glaucoma is very successfully managed
with drugs. Where surgery is necessary it
is limited by poor success in the control
of intraocular pressure and serious
complications. He finished the discussion
with a video of a 27 year old male patient
suffering from angle closure glaucoma
that was successfully treated with laser
periphery iridotomy (LPI).
Presenting ‘Management of Postoperative
Endophthalmitis, Dr. I-van Ho, Retina
Associates, Sydney, Australia, began
with the primary measure to determine
the outcome of postoperative visual
acuity. Secondary outcomes include
complications requiring secondary
endophthalmitic surgery. He ended
his truncated talk by predicting further
standard evaluation of drug management
to decrease postoperative side effects.
Kazuhito Yoneda , Department of
Ophthalmology, Kyoto Prefectural
University of Medicine, Kyoto, Japan,
made an enlightening fast breakdown
of his lecture on ‘Surgery in the Context
of Corneal Opacities’. He quickly scanned
videos of different techniques outlining
corneal topography and confocal
scanning. With almost no time left in
the session, Dr. Martin Brelan, M.D., The
Cleveland Clinic, Ohio, USA, summarized
his discussion on ‘Intrascleral Haptic
Fixation for Secondary IOL Implantation’
using a series of detailed videos. He
quickly demonstrated several methods of
placing sceral IOLs, concluding with his
preferred pull method and demonstrating
that as the session broke up.
APVRSSHOWDAILY | December 8-10, 2016 | Bangkok, Thailand
>> Cont. from Page 1
Prof. Dennis Lam
Professor Andrew Chang, APVRS 2016
Congress Scientific Program Committee
Chairman praised the international
contributors who made up this year’s
organizing committee. He spoke about
the range of sub-topics and the depth
of knowledge brought by this year’s
speakers on such a wide range of current
practices to address future challenges.
He wished all attendees a fruitful and
relaxing visit and hoped to see each at
the second night’s Sea World dinner
extravaganza.
Dr. Taraprasad Das, APVRS President,
welcomed the attendees with a brief
description of the rich history and culture
of Bangkok before going on to discuss
the many events offered this year at the
congress. He spoke of the history of the
APVRS, how it has grown from just a few
doctors to the current 1,800 members.
He spoke further on the changes and
development that he has seen in his
career in treatment and diagnosis of eye
disease, and particularly of the conditions
that are prevalent in the region.
Further, APVRS Secretary General
Prof. Dennis Lam congratulated the
congress organizers for attracting such
a distinguished panel from around
the world and declared that this year’s
meeting is all about breaking barriers,
building bridges and making new friends.
He spoke of the challenges of putting
together the vitreoretinal congress due to
political un-rest in the nation and asked
for a round of applause for Dr. Paisan
Ruamviboonsuk for his tenacity in making
the 2016 event possible. He continued
Dr. Taraprasad Das
Dr. Paisan Ruamviboonsuk
to speak on the developing importance
of Southeast Asian countries for their
rapid growth in the industry matching
the rapid needs of patients. “APVRS has
developed from scratch to strength and is
looking forward to much further growth
by offering fellowships in education, and
expanding care throughout the region,”
Prof. Lam concluded.
and dean of Peking University Eye Center.
Also, she is an honorable president of
the Chinese Ophthalmology Society
and past president of both the Chinese
Ocular Fundus Diseases Society and the
APVRS. Prof. Li spoke briefly giving thanks
to her mentor and colleagues and then
abstracted her award winning lecture to
an appreciative audience.
Yesterday’s opening ceremony was
closely followed by the presentation
of the APVRS Tano lecture award to
this year’s recipient, Prof. Xiaoxin Li,
professor at the Eye Institute of Peking
University People’s Hospital and the
president of Xia Men Eye Center. She
is an academic committee member of
Peking University Health Science Center
Closing the ceremony, Dr. Paisan
Ruamviboonsuk took the stage once
again with gratitude to all and a hope
that the APVRS continues to reach new
heights. “The Congress has become
more and more international, enabling
ophthalmologists from around the world
to meet and network,” he concluded.
Prof. Xiaoxin Li and Dr. Taraprasad Das
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APVRSSHOWDAILY | December 8-10, 2016 | Bangkok, Thailand
Latest Advances in Retinal Surgery
the camera view and it is possible to add
in real-time data, all controlled with head
and eye trackers.
The device’s “shutters” can be opened or
closed, to give the surgeon the option of
viewing as much or little as needed.
by Kaylen Moore
T
he newest developments in retinal
surgery were presented by an
international faculty of respected retina
surgeons, including new visualization
techniques and methods for addressing
challenging conditions.
For example, how do you manage floaters
for patients with persistent symptoms?
Without proper care, they can lead to
visual impairment, migraines and anxiety.
Currently they are treated by YAG laser
vitreolysis, vitrectomy for vitreous floaters
(FOV), or deep anterior vitrectomy.
Opening the session, Dr. Dennis Lam,
M.D., Sun Yat-sen University, Guangzhou,
China, shared a new treatment method,
using Alcon’s Infiniti machine. The
procedure is a two-part surgical option,
emphasized Dr. Lam. Firstly is anterior
vitrectomy without going beyond the
temporary margin. Once this is complete
(usually 1-2 minutes) the patient is asked
to confirm the removal of floaters in
the line of vision. The surgeon will then
proceed with the removal of the elastic
in the anterior chamber, and the entire
procedure is finished in about 10 minutes.
After operating on 100 eyes, 80% of
patients said that they are very satisfied,
and there have been 0 cases of retinal
detachment.
Sharing his findings in endovascular
surgery for retinal vein occlusion (RVO), Dr.
Kazuaki Kadonosono, M.D., professor of
ophthalmology, Yokohama City University
Graduate School of Medicine, Japan,
discussed that in 89 eyes undergoing the
operation, 73 eyes had improved visual
acuity at 6 months, though there was
a relatively high rate of recurrence of
macular edema (23%). Furthermore, Dr.
Kadonosono highlighted cannulation,
and how advanced surgical procedures
can benefit from advanced technology
– which allows surgeons to fix their
arms and reduce tremors, while digital
microscopes allow performance of
delicate procedures more precisely.
On the other hand, Dr. Fernando Arevalo,
M.D., FACS, The Wilmer Eye InstituteJohns Hopkins University School of
Medicine, Baltimore, Maryland, USA,
shared his findings in optic disc pit
(ODP) maculopathy, ending with a lack
of recommendation for JLP, internal
limiting membrane (ILM) peeling, and
gas injections. Although he did suggest
a long period of observation for ODP
maculopathy (12 months) before a
secondary intervention as most patients
will improve over that period.
With some novel technology, Dr.
Anat Loewenstein, M.D., professor of
ophthalmology, Sackler Faculty Tel Aviv,
Israel, got the audience excited about
augmented reality (AR) video microscope
for retina surgery as a replacement of
operating microscopes. Based on a
fighter pilot’s helmet and visual screen,
this new technology uses a head and
eye tracker for seamless controls. The
two ultra-resolution cameras replace
the tradition microscope and project to
a head wearable display (HWD) worn by
the surgeon. The display can show both
Following was Dr. Kenneth Fong, MA
MB BChir (Cambridge), FRCOphth (UK),
FRANZCO (Aust), CCT (UK), AM (Mal),
Sunway Medical Centre, Selangor,
Malaysia, with an in-depth discussion
of the use of dye use during surgery
(chromovitrectomy), and the importance
of excellent contrast, low toxicity, and
high biocompatibility. He concluded by
recommending brilliant blue G (BBG) due
to its variety of benefits.
Then Dr. Maria Berrocal, ophthalmologist
from San Juan, Puerto Rico, took center
stage with scleral buckling surgery with
chandelier illumination. This technique,
noted Dr. Berrocal, while effective, most
surgeons are not trained to complete
it successfully; and many do not like
to perform the procedure due to poor
visibility. This leads to complications
like inadequate buckle placement,
missed breaks, retinal incarceration,
among others. But with light sources,
the optimized visualization can be a
great teaching scenario. A microscope
buckle with chandelier illumination and
illuminated laser takes advantage of
optimal visualization and magnification,
with the retina fully attached on the table,
and possibilities for assistant viewing.
With an impressive decrease in recovery
time, Dr. Chi-Chun Lai, M.D., professor
and chairman of ophthalmology, Chang
Gung Memorial Hospital and Chang
Gung University College of Medicine,
Taiwan, closed out Thursday’s session
with his method for macular hole retinal
detachment (MHRD). With an inverted ILM
clump reposition and auto-blood clot, he
was able to reduce the patient prone time
from two weeks down to one day. His
patients have experienced 96% success
of retina reattachment, and his tested
collagen type 4 also improved healing of
the macular hole.
APVRSSHOWDAILY | December 8-10, 2016 | Bangkok, Thailand
Pictures From Around the
Ophthalmic Conference World
East Vs. West match at ASCRS
New Orleans
Bejeweled burger at AAO
Chicago
Allergan booth looking homey at
ESCRS Copenhagen
Dancers at APAO Taipei
Posterior segment PowerPoint
at an AOS Bangkok retina forum
Making clinical points on a
motorbike at AAO Las Vegas
Augmented Reality demos at
Abbott booth, APACRS Bali
Getting local at a Malaysia-Singapore
meeting in Kuching
Ancient eye anatomy at
RANZCO Melbourne
Local talent at APVRS Sydney
Smiling at Alcon symposium at RANZCO
Wellington
11
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