Year : 2018 | Volume
: 66 | Issue : 12 | Page : 1668--1670
A perspective on the evolving field of vitreoretinal diseases
Future Vision Eye Care and Research Centre, Mumbai, India
Dr. Sabyasachi Sengupta
Future Vision Eye Care and Research Centre, Mumbai
|How to cite this article:|
Sengupta S. A perspective on the evolving field of vitreoretinal diseases.Indian J Ophthalmol 2018;66:1668-1670
|How to cite this URL:|
Sengupta S. A perspective on the evolving field of vitreoretinal diseases. Indian J Ophthalmol [serial online] 2018 [cited 2018 Dec 15 ];66:1668-1670
Available from: http://www.ijo.in/text.asp?2018/66/12/1668/245621
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.
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