Retina Summit Karlsruhe 2009

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Retina Summit Karlsruhe 2009 Expert Rev. Ophthalmol. 4(3), 223–225 (2009)

Albert J Augustin† and Stanislao Rizzo

Retina Summit Karlsruhe 2009 Karlsruhe, Germany, 28–29 March 2009

Author for correspondence Department of Ophthalmology, Klinikum Karlsruhe, Moltkestrasse 90, 76133 Karlsruhe, Germany Tel.: +49 721 974 2001 Fax: +49 721 974 2009 [email protected]

During the this year´s Retina Summit Karlsruhe, an international expert faculty of 20 highly renowned retina specialists and more than 300 participants found their way to Karlsruhe to share their knowledge of the latest trends in surgical technology and pharmacology. After an angiography course on Friday, the 1-day symposium of almost 40 short lectures covered recent developments in age-related macular degeneration and diabetic macular edema, and the implications and challenges associated with microincision vitrectomy surgery, new devices and advances in imaging technologies.

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Microincision vitrectomy surgery

At the Retina Summit Karlsruhe 2009, the first two sessions focused on news in microincision surgery and vitreoretinal surgery in general. Although, in the past few years, new surgical techniques using 23- and 25-gauge technologies have claimed their field, anatomical difficulties and technical limitations are challenges for surgery in the posterior chamber. The present advantages of microincision vitrectomy surgery technologies include better access to the surgical field owing to smaller blades and better intraoperative control of fluidics. In the hands of an experienced surgeon, this can be considered the safer procedure compared with other techniques. However, some problems remain; Donald D’Amico (Weill Cornell Medical College, NY, USA) gave some advice to overcome these. He recommended using the newest instruments, which are less flexible, have enhanced handles, incision markers on their back, redesigned larger diameter cannules, which are are less flow-limiting, and angled incision blades. Moreover, he suggested the use of mixed-gauge surgery, combining the advantages of 25- or 23-gauge incision and 20-gauge sclerotomy. Several speakers agreed that the best results will always be achieved with thorough consideration and case selection, choosing the appropriate methods according to the specific requirements of each case. The participants were reminded that this is, indeed, a substantial advance. However, as with every new method, a careful evaluation of the surgical performance, including the long-term www.expert-reviews.com

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results, is mandatory and, therefore, strongly recommended. Stanislao Rizzo (Ospedale Santa Chiara, Pisa, Italy) relieved any fears of increased endophthalmitis rates, after commenting on results from the Microsurgical Safety Task Force. He stated that even the increased rates were still almost zero, and no basic differences in the bacterial entities were found after 25- and 20-gauge sclerotomies. Appropriate pre- and peri-operative hygiene, in combination with povidone–iodine treatment, should to prevent infections. Furthermore, careful surgery with angled incisions seems advantageous, as three-quarters of the endophthalmitis cases in his comparative study were observed to have straight sclerotomy ports. A tapered trocar exit instead of a straight pullout may eliminate vitreous incarceration, and conjunctival displacement should be performed with a cotton tip rather than with hard instruments. This helps to avoid microholes, which are a potential safety risk. Further news from the technological frontier

Turning to a different kind of surgery, Gisbert Richard (Universitäts-Augenklinik, Hamburg, Germany) presented fascinating results of a 6-month Phase I trial of retinal chip implants in blind patients with retinitis pigmentosa. Images from a glasses-based camera travel wirelessly to the retina-implanted 49-electrode chip, enabling the patients (on a 100% basis) to discern horizontal and vertical test lines, some set shapes and even motion, although the impressions were

© 2009 Expert Reviews Ltd

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not always stable. Setting the appropriate parameters of pulse numbers and amplitudes are now the main issues that need to be addressed but, with an excellent tolerability, a multicenter study is currently underway. Suprachoroidal catheters, which were presented by Tom Chang (CA, USA) and Manfred Tetz (Augentagesklinik Spreebogen, Berlin, Germany), have been demonstrated to be highly effective in canaloplasties for glaucoma surgery. Moreover, they may open new doors for site-specific drug applications in macular diseases. The flexible glass fibers that follow the shape of the globe can be illuminated and, thus, easily located in order to advance precisely to the desired location. Here, the drug can be deposited to exert its effect specifically at the lesion. After promising animal and Phase I results, several Phase II studies are currently in preparation and even in progress. Optical coherence tomography: what you see is what you get

Optical coherence tomography (OCT) is a major breakthrough in the field of instrumental imaging. Taking advantage of different scattering and reflection properties of the various tissues, OCT allows for fast, noncontact and high-resolution images of the retina, making it a ‘noninvasive in vivo histology’. Technological progress has virtually rocketed and, by now, the fourth-generation OCT has arrived. Ursula Schmidt-Erfurth (Universitäts-Augenklinik, Vienna, Austria) compared the latest advances of the fourth-generation OCT (Cirrus™, Carl Zeiss Meditec, Inc., Germany), based on spectral domain (or Fourier domain) technology, as opposed to the time domain-based third-generation OCT (Stratus™, Carl Zeiss Meditec, Inc.), with sequential capture of information along the time line. Showing some very impressive slides, with a resolution of 3 µm, and realistic 3D images, she pointed out that the increased number of scans, lower speckle noise and real-time tracking, as well as the novel raster scanning mode, now allow not only much better layer distinction but also site identification, which makes it a viable method to follow retinal thickening and edema and to monitor age-related macular degeneration (AMD) therapy. Now, OCT can even differentiate between intra- and sub-retinal fluid. However, owing to different calculation algorithms, Cirrus and Stratus measurements of the same sites may differ, and segmentation reliability depends on the respective disease. Thorsten Böker (Klinikum Dortmund gGmbH, Dortmund, Germany) demonstrated the advantages of the combined use of OCT and other imaging technologies, such as scanning laser opthalmoscopy for fluorescein and even indocyanine green angiography. Further enhancements, such as adaptive optics and tracking, as well as multifocal electroretinogram, may help to improve both the resolution and the overall information yield. AMD & diabetic macular edema: old drugs, new drugs & new strategies

Having seemed promising in the past few years, recently, intravitreal cortico­steroids seem to have lost some degree of relevance owing to increases in intraocular pressure and other side effects. 224

Susan Bressler (The Wilmer Eye Institute, MD, USA) demonstrated that, in a comparative diabetic macular edema study on 1- and 4-mg triamcinolone and laser photocoagulation, “laser wins out on steroids in all fields”. Steroid benefits were only found during the first 4 months; past that period, more people lost visual acuity over time with steroids than with laser, where the visual acuity stayed unaffected over 3 years. Concepts of fluocinoloneand triamcinolone-deposit implants should be evaluated with care, considering the glaucoma- and cataract-promoting properties observed. However, use of dexamethasone may be revived, as was reported in Paolo Lanzetta’s (University of Udine, Udine, Italy) presentation on dexamethasone devices, especially in combination with laser treatment, as this sustains the initial effects over time. Besides the inf lammatory component, choroidal neo­ vascularization is the main feature in AMD. Thus, several antiVEGF antibodies are currently under evaluation in clinical trials, compared with either each other or, in a new concept, in combination with photodynamic therapy, as was presented by Antonia Joussen (Universitäts-Augenklinik, Düsseldorf, Germany). Joussen reported the results from the clinical studies FOCUS and PROTECT, demonstrating significant superiority of the combination versus photodynamic therapy alone. A stabilization of the increase in visual acuity was achieved but not maintained with photodynamic therapy alone. In order to manage the inflammatory component, addition of steroids to form a triple combination proved highly effective in mouse experiments. Joussen pointed out that this concept also works in humans, as has already been shown in a case series by Augustin, who had conceived and successfully evaluated a combination of photodynamic therapy, dexamethasone and avastin in humans. This case series is now being investigated in a prospective trial (Reduced Fluence Visudyne-Anti-VEGF-Dexamethasone in Combination for Age-related Macular Degeneration Lesions [RADICAL]) with the results at 6 months being very promising. The 1-year results are expected this summer. Combination strategies may, thus, be the best way to exploit the advantages and avoid the drawbacks of the individual single drugs. Does AMD go to the heart?

Toward the end of the afternoon, Curt Diehm (Klinikum Karlsbad-Langensteinbach, Karlsbad, Germany) aroused special attention from the audience by pointing out that AMD and cardiovascular diseases may not only share the same risk factors but possibly even a common etiology. He commented on the results of the Australian Blue Mountains cohort study and other recent data that found distinct evidence of an increased risk for cardiovascular mortality in connection with AMD. Increased serum cystatin C levels, a measure of kidney function, were also associated with higher risks for AMD. Moreover, a meta-analysis revealed that intravitreal administration of ranibizumab (Lucentis®) was associated with significantly more cardiovascular events than placebo. As a consequence, AMD patients should definitely be informed and urged to change their lifestyles to meet the recommendations of the American Heart Association (i.e., quit smoking, control bodyweight and blood pressure, eat healthily and exercise). Expert Rev. Ophthalmol. 4(3), (2009)

Retina Summit Karlsruhe 2009

At the end of the day, this relaxed and yet exciting meeting succeeded in combining top-level research with scientific communication, verbal lectures with instructive videotapes and clinical hot topics with practical trends and outlooks. We were proud to present a number of the currently most prominent researchers in the field, whom we thank for their participation and look forward to seeing again. Affiliations •

Albert J Augustin, MD Department of Ophthalmology, University of Mainz, Langenbeckstrasse 1, 55101 Mainz, Germany; and, Department of Ophthalmology, Klinikum Karlsruhe, Moltkestrasse 90, 76133 Karlsruhe, Germany Tel.: +49 721 974 2001 Fax: +49 721 974 2009 [email protected]

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Meeting Report

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. No writing assistance was utilized in the production of this manuscript.

Stanislao Rizzo, MD Chairman UO Chirurgia Oftalmica, S Chiara Hospital via Roma, Azienda Opsedaliero-Universitaria Pisana, Pisa, Italy Tel.: +39 050 993 658 [email protected]

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