SOUTH AFRICAN VITREORETINAL MEETING

Our annual SAVRS meeting was held at the beautiful Simola country club in Knysna…10 minutes from my practice which made it a really convenient venue for me this yr.

We were honoured to have Barbara Parolini and Nicola Ghazi, both internationally respected retinal expert address us on a few buzz words in vitreoretinal disease.

Below is an executive summary of their talks:

  • Prevalence of CME post PPV is 10.4%
  • Prevalence of CME post PPV with combined phaco 15.2%, but no statistically significant difference shown
  • 10% CME found in post operative patients with no pre- operative CME
  • Combined Phaco/PPV is a risk factor for post operative CME in patients without pre-operative CME
  • Post operative CME is a difficult entity to treat: Prednisolone acetate 10mg in drop form, or Ozurdex
  • Suggestion is that one waits a few months in between procedures and try not to combine them.
  • The burning question is then: should one be using pre-operative prophylactic steroids in these cases..??

Lamellar hole surgery:

  • Lamellar holes are breaks in the inner retinal layer in the fovea not extending to the RPE
  • Do not operate these unless the VA is significantly decreased
  • Don’t operate these if they have concomitant dense ERM

Nicola Ghazi:

Management of diabetic macular oedema:

  • Ozurdex implants are seen to be most beneficial in groups with diffuse macular odemea
  • Ozurdex also useful in pseudophakes,poor responders to topical therapy
  • Eyelea(Aflibercept) is a new anti-VEGF that traps VEGF between its molecular arms whereas Avastin and Lucentis still allow one side of the arm to bind to VEGF. This characteristic of Eyelea allows for longer intervals between intravitreal injections. This will result in an annual average number of injections of 4-6
  • There is a new coined term in ERM in diabetics: trans retinal fibrosis: This has both pre-retinal and subretinal components that are adhered together-do not touch these surgically!
  • Approach to non centre involving DME-in the provincial clinical setting, grid/focal laser still seem to be the gold standard
  • If however the Subfield thickness on OCT is >250 microns, then anti-VEGF treatment is indicated
  • Positive predictive factors on OCT for good visual outcome in CME are vertical columns, particularly central. These are known as central retinal processes. If cysts are confluent then prognosis is poorer

Advances in the management of diabetic tractional retinal detachement:

  • Avastin/Lucentis:
  • Can be used as an adjunct in PDR
  • Usefeul prior to vitrectomy for vitreous Hg
  • Can be used at the end of the vitrectomy post Hg
  • If you inject Avastin prior to vitrectomy for PDR, do not wait >15 days from time of injection to surgery. Dose is 1.25mg
  • If there are very adherent plaques at the disc, don’t induce a PVD. Rather truncate the vitreous here as much as possible

Barbara Parolini: The macular hole study

Predictors of hole closure:

  • Stage of the hole
  • Hole duration
  • Dye used
  • Gas used
  • Tamponade incomplete?
  • completeness of vitrectomy and lens status

There is a 90% probability of hole closure if surgery is done early, but one should attempt the surgery irrespective of duration

The type of dye used does not seem to be relevant

Post operative positioning is a contentious issue: Position for a short duration. Consensus seems to be 1 week

A complete vitrectomy increases the chance of hole closure

Predictors of post op BCVA:

  • The better the pre-op VA, the less the gain in post-op VA
  • Pseudophakes may gain more VA
  • A combined procedure does not show worse outcomes
  • post-op retinal detachments: the largest factor was having intra-operative retinal detachments

Dr Parolini described her technique of ILM flaps with regards macular hole closure and noted that it seemed to improve hole closure rates, especially in chronic holes

Last note on questions from the audience: With regards traumatic macular holes in children,wait 2-3 months as they usually close spontaneously