Retina debates spotlighted in AAO Annual Meeting session

ONLINE EXCLUSIVE

January 2024

by Ellen Stodola
Editorial Co-Director

In a retina session at the 2023 AAO Annual Meeting, presenters debated the pros and cons of various topics. 

Maria Berrocal, MD, argued the pro side for early vitrectomy in diabetic retinopathy. Retinopathy doesn’t progress in diabetic eyes with a complete posterior vitreous detachment (PVD), she said, also noting that pars plana vitrectomy (PPV) with hyaloid removal and panretinal photocoagulation (PRP) stabilizes eyes permanently. PRP is not a permanent solution in eyes with an attached hyaloid, and anti-VEGFs are not a permanent solution for diabetic eyes. She also noted poor compliance in diabetic patients. 

The status of the hyaloid is determinant of retinopathy progression, she said, adding that eyes with total PVD stabilize long term and do not develop TRD or disease progression.

Anti-VEGFs are not a permanent solution and should be used with extreme caution as the sole treatment of proliferative diabetic retinopathy (PDR) in diabetics without a total PVD. 

For 40 years we’ve known early vitrectomy in type 1 diabetics gives better outcomes, Dr. Berrocal said, and suggested using vitrectomy as prevention and not as a last resort.

Vitrectomy for diabetics with PDR and an attached hyaloid prevents progression of the disease and stabilizes eyes, she said. Imaging modalities allow for detection of eyes with complete PVD, and vitrectomy is more cost effective than anti-VEGFs. With improvements in vitrectomy, it is time to reconsider the indications of vitrectomy for diabetic patients, she said. The question that remains is when in the course of the disease is the ideal time to perform a vitrectomy in PDR.

William Smiddy, MD, argued the con side of early vitrectomy in diabetic retinopathy. First, you have to define what is meant by “early.” Formerly, this might have meant 3–6 months, he said, but now it’s immediately to a few weeks. He noted that there are only two randomized trials that he is aware of for timing diabetic PPV. “We currently practice in a different era, with anti-VEGF therapy as a powerful tool,” he said. 

Dr. Smiddy went on to highlight who might initially be a better candidate for deferring PPV; this is in less severe or partially treated patients or in those with medical or social comorbidities. Dr. Smiddy argued that the answer to this debate is not a categorically binary answer. We have viable complementary options in the current anti-VEGF therapeutic era, he said. Some patients are suited for a “go slow” approach, and some are more suitable for early intervention.

In the end, Dr. Smiddy won the debate, with 51% of the audience voting for argument.

Another debate covered “Current Complement Inhibition Therapy for Geographic Atrophy is Acceptable.”

Usha Chakravarthy, PhD, presented the pro side. Geographic atrophy (GA) is an undisputed cause of vision loss. Worldwide, GA accounts for vision loss in about 5 million people. Dr. Chakravarthy posed several questions and data to support her case. Is there a rationale for targeting the complement pathway? What is the evidence that targeting the complement pathways result in reduction in GA growth rate? Can we address the discord between reduced GA expansion and absence of commensurate visual benefit? Can we apply knowledge from prior studies to the Phase 3 data to unmake potential function benefit?

Current complement inhibition strategies are an important step forward in the search for treatments to tackle GA, she said. The stepwise improvement in effectiveness is a developmental process leading to personalized healthcare and precision medicine, which can only occur with accruing knowledge maximizing benefit and minimizing risk and adverse events. This is necessary for innovation and investment in this disease area, which represents a huge unmet need, she said.

Richard Spaide, MD, presented the con side. Although complement has been found in drusen and the choriocapillaris, both outside of the blood ocular barrier, current treatments are given inside the blood-ocular barrier, he said. Complement is used in normal homeostasis in the eye, and complement knockout in animal models has resulted in retinal degeneration. Current complement inhibition was approved only because of an imaging test, autofluorescence, even though readily available data showed the patients had no functional benefit, as compared with sham control.

He mentioned pegcetacoplan and said that treatment groups were not different than sham in terms of the functional endpoints, best corrected visual acuity, maximum reading speed, Functional Reading Independence Index, and mean threshold microperimetry. He also said there was no difference between treatment and sham for avacincaptad pegol in terms of the reported functional outcomes, BCVA, and low luminance VA. For both drugs, the patient-reported outcome measure, the VFQ-25, showed no treatment benefit. 

Current complement inhibition has treatment hurdles, he said. The first is it should show treatment benefit to the patient, and the second is that the value of the treatment should be acceptable to society, as measured by cost per quality adjusted life years. 

When polled, the audience agree with Dr. Spaide, with 83% voting for his argument. 


About the physicians 

Maria Berrocal, MD
CEO
Drs. Berrocal & Associates
San Juan, Puerto Rico

Usha Chakravarthy, PhD, MBBS
Queen’s University Belfast
Belfast, United Kingdom 

William Smiddy, MD
Bascom Palmer Eye Institute
University of Miami
Miami, Florida

Richard Spaide, MD
Vitreous, Retina, Macula Consultants of New York
New York, New York

Relevant disclosures

Berrocal: Various
Chakravarthy: Various
Smiddy: None
Spaide: Various

Contact

Berrocal: mariahberrocal@hotmail.com
Chakravarthy: u.chakravarthy@qub.ac.uk
Smiddy: wsmiddy@med.miami.edu
Spaide: rickspaide@gmail.com