|Year : 2018 | Volume
| Issue : 12 | Page : 1668-1670
A perspective on the evolving field of vitreoretinal diseases
Future Vision Eye Care and Research Centre, Mumbai, India
|Date of Web Publication||19-Nov-2018|
Dr. Sabyasachi Sengupta
Future Vision Eye Care and Research Centre, Mumbai
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sengupta S. A perspective on the evolving field of vitreoretinal diseases. Indian J Ophthalmol 2018;66:1668-70
The subspecialty of vitreoretinal surgery is seeing unprecedented advancements over the past decade. There is a proliferation of literature on diseases of the retina, vitreous, and choroid with emphasis on every vital aspect such as pathogenesis, molecular understanding, imaging, and treatment. The Indian Journal of Ophthalmology (IJO) is also experiencing a record number of submissions, with the number set to cross 2000 by the end of 2018. Not surprisingly, more than 20% of submissions to the IJO are related to vitreoretinal diseases, mimicking the overall mood and direction of ophthalmic literature. This sudden overdrive has lead to many national and international organizations and societies launching retina subspecialty journals over the past 2 years, thus providing authors with more opportunities to exhibit their niche work to a global audience. However, with literature evolving at breakneck speed, it is often difficult to keep up. In this editorial, we will take a look at the directions in which literature is evolving in the field of vitreoretina to get a clear perspective. This special issue has also been curated carefully in collaboration with the Vitreoretina Society of India to bring the best and latest in this subspecialty to our readership.
Perhaps the greatest evolution has been in the field of imaging modalities of the retina and choroid. An influential article by Staurenghi et al. and the international nomenclature for optical coherence tomography (OCT) panel shed light on the anatomic landmarks in the OCT image and clearly distinguished that there were differences in the outputs from the Zeiss Cirrus OCT and the Heidelberg Spectralis OCT. The introduction of the swept source OCT and enhanced depth imaging (EDI) led to introduction of terminologies such as pachychoroid (submacular choroidal thickness ≥ 400 μm) and leptochoroid almost half a decade ago. Since then, we know that pachychoroid is associated with an entire disease spectrum including central serous chorioretinopathy (CSCR), pachychoroid pigment epitheliopathy, neovasculopathy, and polypoidal choroidal vasculopathy (PCV), each with its unique features. Current research is looking at whether those with CSCR with pachychoroid differ from those who do not have pachychoroid in terms of spontaneous resolution rates, chronicity, and recurrences. This issue of the IJO has excellent review articles on management of CSCR and PCV that bring out important pathogenetic and treatment considerations., Many other newer diseases have been uncovered by EDI imaging and terminologies coined such as focal choroidal excavation, peripapillary pachychoroid, choroidal knuckle, dome-shaped macula, and peripapillary choroidal cavitation. Looking at retinal diseases, newer concepts such as disorganized inner retinal layer (DRIL) and outer retinal tubulations have been described over the past few years, and each of these is a poor prognostic factor for visual improvement and response to anti-vascular endothelial growth factor (VEGF) injections. Vitreoretinal interface diseases such as central bouquet abnormalities, ectopic inner foveal layer (EIFL), and lamellar hole associated epiretinal proliferation (LHEP) have been described to better characterize the loosely used term of epiretinal membrane. It is beyond the scope of this editorial to discuss each in detail, but those interested can sift through literature to get a better grip of these newer concepts.
The other revolution in retinal disease imaging has come in the form of OCT angiography (OCTA). This technology, though in its infancy and limited by unreliability due to eye movements during capture (motion artifact), has come a long way in characterizing retinal and choroidal disease vascularity. The ability to separately delineate the inner and outer retinal capillary plexus, which is not possible by conventional fluorescein angiography, is exciting, and research is rapidly progressing to see which plexus is predominantly involved in different retinal vascular diseases. In addition to obvious applications in diabetic macular edema (DME) and vein occlusions, OCTA has found tremendous applications in diseases such as macular telangiectasia, acute macular neuroretinopathy (AMN), and paracentral acute middle maculopathy (PAMM) to clearly delineate the very localized retinal ischemia in these conditions. Oncologists have also found a new way of imaging vascular tumors and understanding disease characteristics and treatment effects better. This issue of the IJO has a very lucid panel discussion on clinical applications and current role of OCTA in vitreoretinal diseases which would be of great interest to our readers. Other imaging modalities such as fundus autofluorescence, near-infrared reflectance imaging, and composite multicolor imaging offered by the Heidelberg SPECTRALIS HRA machine have also improved our understanding of many disease processes.
In terms of therapeutics in retinal diseases, we have seen Aflibercept emerging as an alternative for the well-established ranibizumab for most conditions, though the initial promise of longer duration of action and increased in vitro potency against VEGF has not translated into clinically meaningful differences in most clinical trials. In terms of treatment protocols, the treat-and-extend regimen has emerged to be a good balance between monthly treatments and Pro-Re-Nata (PRN) or as and when required protocols. However, implementing treat-and-extend in our resource-poor scenario is an altogether different challenge, and treatment protocols are mostly driven by patient's economics rather than pure science. Newer and very promising drugs on the horizon which may make it to our clinics within the coming year are Brolucizumab and Abicipar, while longer acting depot preparations of ranibizumab are nearing completion of clinical trials. These will no doubt boost our armamentarium for treating retinal diseases and hopefully improve patient outcomes. Sticking to therapeutics, the results of the DRCR Protocol S have intensified the debate on the use of anti-VEGF monotherapy for treating proliferative diabetic retinopathy. However, looking closely at the 5-year results, a strictly controlled clinical trial setting also had a considerable loss to follow-up. Considering behavioral patterns of our patients and inability to afford multiple intravitreal injections, it is safe to assume that panretinal photocoagulation is still the best treatment for our patients. Management protocols for DME have also evolved significantly, and this issue of the IJO carries a review article on evidence-based management of DME. Finally, repeated injections of anti-VEGF agents have raised concerns of increase in size of geographic atrophy in eyes with neovascular AMD. To study this more effectively, two consensus meetings were recently held by the Classification of Atrophy Meeting (CAM) group. It was recommended that future studies utilize a multimodal imaging approach to detect geographic atrophy progression including color fundus photography, confocal fundus autofluorescence, confocal near-infrared reflectance, and high-resolution OCT volume scans. In addition, fluorescein and indocyanine angiography was recommended for certain special situations.
Surgical advances in vitreoretinal diseases consist of 27-guage vitrectomy with good results in most scenarios. The advent of the Nguenity 3D visualization system for vitreoretinal surgery using polarized 3D glasses and real-time display of the operative field on a large monitor promises to improve surgical results while helping vitreoretinal surgeons maintain an ergonomic position while operating. Adaptive optics is another domain of retinal imaging that will improve resolution and help us take a closer look at individual cells in vivo. Finally, the available RPE65 gene therapy for Leber's congenital amaurosis has opened many exciting new possibilities for management of retinal dystrophies and restored faith in the approach we are taking toward managing these diseases.
In conclusion, we are in an exciting era where rapid change is the only constant, especially when it comes to the field of vitreoretinal diseases. As physicians, it is important for us to imbibe these changes and improve outcomes for our patients. I have enlisted many new concepts in this editorial to pique the interest of our readers and provide a perspective of where we may be headed. The natural progression of understanding core concepts is more questions, which, when formalized, can turn into research ideas that can be pursued and papers published. Indian ophthalmology is in the best possible position to contribute to ophthalmic literature and vitreoretinal diseases is one area where much is done, yet much remains to be done. Let us do more and leverage our tremendous intellectual capital by making meaningful contributions to global scientific literature.
| References|| |
Staurenghi G, Sadda S, Chakravarthy U, Spaide RF, International Nomenclature for Optical Coherence Tomography (IN•OCT) Panel. Proposed lexicon for anatomic landmarks in normal posterior segment spectral-domain optical coherence tomography: The IN•OCT consensus. Ophthalmology 2014;121:1572-8.
Warrow DJ, Hoang QV, Freund KB. Pachychoroid pigment epitheliopathy. Retina 2013;33:1659-72.
Akkaya S. Spectrum of pachychoroid diseases. Int Ophthalmol 2018;38:2239-46.
Ho CPS, Lai TYY. Current management strategy of polypoidal choroidal vasculopathy. Indian J Ophthalmol 2018;66:1727-35. [Full text]
Chhablani J, Anantharaman G, Behar-Cohen F, Boon C, Manayath G, Singh R. Management of central serous chorioretinopathy: Expert panel discussion. Indian J Ophthalmol 2018;66:1700-3. [Full text]
Margolis R, Mukkamala SK, Jampol LM, Spaide RF, Ober MD, Sorenson JA, et al
. The expanded spectrum of focal choroidal excavation. Arch Ophthalmol 2011;129:1320-5.
Phasukkijwatana N, Freund KB, Dolz-Marco R, Al-Sheikh M, Keane PA, Egan CA, et al
. Peripapillary pachychoroid syndrome. Retina 2018;38:1652-67.
Pilotto E, Guidolin F, Parravano M, Viola F, De Geronimo D, Convento E, et al
. Morphofunctional evaluation in dome-shaped macula: A microperimetry and optical coherence tomography study. Retina 2018;38:922-30.
Yeh S-I, Chang W-C, Wu C-H, Lan Y-W, Hsieh J-W, Tsai S, et al
. Characteristics of peripapillarychoroidal cavitation detected by optical coherence tomography. Ophthalmology 2013;120:544-52.
Sun JK, Lin MM, Lammer J, Prager S, Sarangi R, Silva PS, et al
. Disorganization of the retinal inner layers as a predictor of visual acuity in eyes with center-involved diabetic macular edema. JAMA Ophthalmol 2014;132:1309-16.
Lee JY, Folgar FA, Maguire MG, Ying G, Toth CA, Martin DF, et al
. Outer retinal tubulation in the comparison of age-related macular degeneration treatments trials (CATT). Ophthalmology 2014;121:2423-31.
Govetto A, Bhavsar KV, Virgili G, Gerber MJ, Freund KB, Curcio CA, et al
. Tractional abnormalities of the central foveal bouquet in epiretinal membranes: clinical spectrum and pathophysiological perspectives. Am J Ophthalmol 2017;184:167-80.
SpaideRF, Fujimoto JG, WaheedNK, Sadda SR, Staurenghi G. Optical coherence tomography angiography. Prog Retin Eye Res 2018;64:1-55.
Agarwal A, Grewal DS, Jaffe GJ, Stewart MW, Srivastava S, Gupta V. Current role of optical coherence tomography angiography: Expert panel discussion. Indian J Ophthalmol 2018;66:1696-9. [Full text]
Gross JG, Glassman AR, Liu D, Sun JK, Antoszyk AN, Baker CW, et al
. Five- year outcomes of panretinal photocoagulation vs intravitreous ranibizumab for proliferative diabetic retinopathy: A randomized clinical trial. JAMA Ophthalmol 2018;136:1138-48.
Grunwald JE, Pistilli M, Daniel E, Ying G-S, Pan W, Jaffe GJ, et al
. Incidence and growth of geographic atrophy during 5 years of Comparison of Age-related macular degeneration Treatments Trials (CATT). Ophthalmology 2017;124:97-104.
Holz FG, Sadda SR, Staurenghi G, Lindner M, Bird AC, Blodi BA, et al
. Imaging protocols in clinical studies in advanced age-related macular degeneration: Recommendations from Classification of Atrophy Consensus meetings. Ophthalmology 2017;124:464-78.
| Authors|| |
Dr Sabyasachi Sengupta is a consultant vitreoretinal surgeon at Future Vision Eye Care, Mumbai. He completed his Diploma in Ophthalmology from JIPMER, Pondicherry followed by DNB at Aravind Eye Hospital, Pondicherry. He then completed a research – cum – clinical fellowship in surgical vitreoretinal disorders at the prestigious Sankara Nethralaya, Chennai, and went on to pursue a research fellowship at Wilmer Eye Institute, Johns Hopkins University School of Medicine, USA. He was awarded the Mc Cartney prize by the Royal College of Ophthalmologist's in London for securing the highest marks in Ocular Pathology in FRCOphth in 2010 and had the distinction of being the first ever non-British national to receive this award. He was the recipient of Dr G. Venkataswamy Gold Medal in DNB Ophthalmology in 2009. He was awarded the best research fellow as well as the best outgoing fellow 2010 – 2012 at Sankara Nethralaya. He was recently awarded the “Young Achievers Award” by the Vidarbha Ophthalmic Society for his outstanding achievements and contribution to ophthalmic research in India.
He has published 75 articles in peer-reviewed journals and presented more than 50 papers and posters in national and international conferences. He is the current associate editor of the Indian journal of Ophthalmology and a regular reviewer for many journals including JAMA Ophthalmology and Ophthalmology. He is the founder and director of Senguptas Research Academy, offering E-learning lectures on research methodology and services for manuscript preparation.