Summary of VBS 2021: The Force Awakens - Virtual Episode 1

Vlad Matei, M.D.

The first episode of VBS 2021 featured excellent discussions and numerous surgical videos from an eclectic group of presenters. If you missed the live meeting, the following is a summary of its take-home points.

The program hit the ground running with a series of presentations on the optimal secondary intraocular lens (IOL) procedure for the vitreoretinal surgeon. Maria Berrocal, M.D., advocated for sutureless 3-piece IOL placement with the modified Yamane technique, citing advantages including the avoidance of suture-related complications and a relatively low risk of pupil distortion or corneal decompensation. She makes the scleral tunnels for the IOL haptics with a 27-gauge needle, 1.5-2.5 mm in length and 2 mm from the corneal limbus.

Joseph Coney, M.D., then spoke in favor of scleral fixation of IOLs with eyelets, such as the Bausch & Lomb Akreos IOL, using Gore-Tex suture, noting that Gore-Tex suture seems to be more durable than polypropylene suture, which carries a well-documented risk of late-onset disintegration leading to IOL dislocation. He recommended fixating the IOL 3 mm posterior to the corneal limbus to reduce the risk of iris chafing by the IOL, as well as burying the suture knots in the sclerotomies to reduce the risk of postoperative suture erosion through conjunctiva.

Next, Ninel Gregori, M.D., presented her technique for iris-sutured IOL fixation, pointing out that this technique not only avoids the risk of suture erosion, but is also especially beneficial in cases where thin sclera or subconjunctival scarring makes scleral fixation precarious. Her pearls included placing two sutures around each haptic by the McCannel technique with 3-1-1-1 knots to reduce the risk of IOL dislocation, and passing the sutures as far away from the pupillary border as possible to reduce the risk of pupillary distortion.

Finally, Katherine Talcott, M.D., spoke in favor of anterior chamber IOL (ACIOL) placement, referring to the long and favorable track record of this technique in terms of safety, durability, and visual outcomes. She recommended inserting the ACIOL through a scleral tunnel made 1-2 mm posterior to the corneal limbus, as well as constricting the pupil with a cholinergic agent beforehand and using a Sheets glide to make insertion easier and safer.

Sutureless scleral fixation emerged as the preferred technique in the audience poll which concluded this session. Panelists in the associated discussion emphasized that vitreoretinal surgeons should ideally learn all of the available techniques, since each has unique advantages and disadvantages, and since the optimal technique depends on the circumstances of each patient. Regardless of technique, all patients should be counseled to never rub their eyes postoperatively, as eye rubbing may precipitate IOL dislocation.

In the medical-retina presentation, Lejla Vajzovic, M.D., reviewed two upcoming surgical approaches to neovascular age-related macular degeneration (nAMD) management, namely the ranibizumab-releasing Port Delivery System (PDS) implant by Genentech and RGX-314, a gene-therapy medication designed for one-time subretinal delivery, by REGENXBIO. The PDS has completed phase-3 trials, while RGX-314 will be undergoing phase-3 trials this year. Data on each product suggests that these therapies may dramatically reduce the number of intravitreal injections required to keep nAMD under control, but each product requires a surgical technique which is currently not frequently performed by most vitreoretinal surgeons. The subsequent panel discussion emphasized that the benefit of reducing injection burden must be carefully weighed against the risks of surgical management of nAMD for each patient.

The Lightning Surgical Rounds presentations yielded numerous surgical pearls. Matthew Cunningham, M.D., showed a video of a diabetic tractional retinal detachment repair which demonstrated how very adherent epiretinal membranes tend to be in these cases and reminded us that, once the surgeon relieves all membranous traction on the macula, persistence in peeling adherent, but clinically insignificant, membranes beyond the macula increases the risk of iatrogenic retinal breaks. Kristen Harris-Nwanyanwu, M.D., presented a video of complex retinal detachment repair and demonstrated effective peeling of proliferative vitreoretinopathy (PVR) membranes with internal limiting membrane (ILM) forceps in a posterior-anterior direction from the optic disc. The video by Marianeli Rodriguez, M.D., featured a rare case of bilateral tractional full-thickness macular holes secondary to proliferative diabetic retinopathy. She showed how despite an irregular hole configuration and associated macular atrophy, a standard pars plana vitrectomy (PPV) with ILM peel and gas tamponade can successfully close such holes.

Following the Lightning Rounds, Yewlin Chee, M.D., presented several videos and pearls on the repair of posterior segment trauma. She recommended placing an encircling scleral buckle in most cases at the time of PPV for posterior segment trauma, due to the high risk of PVR. She then presented a case of retinal detachment following chorioretinitis sclopetaria with several important pearls: In such cases the retinal breaks tend to occur at the edge of the chorioretinal scar. The fibrotic membranes associated with this condition extend through the retina, with contiguous epiretinal and subretinal portions. Peeling the ILM first may help to identify and lift the epiretinal component. The subretinal component can be very difficult to remove and in many cases it is sufficient to merely segment it from the epiretinal component. Dr. Chee ultimately won the audience-voted award for best surgical video.

The most unique part of this VBS episode was the panel discussion on diversity, equity, and inclusion in the retina specialty. One fact mentioned in this discussion is that underrepresented minorities account for only 12% of all physicians and less than 7% of ophthalmologists. Discussants advised that more data needs to be collected on which career stages and practice settings suffer the most from underrepresentation, and that increased mentorship through professional societies may help to correct this problem.

The final session focused on surgery in the setting of uveitis, with a talk by Lisa Faia, M.D. The most important take-home point from this session is that uveitis patients should have total quiessence of intraocular inflammation for at least 3 months prior to any eye surgery. In addition, preoperatively patients should have a prophylactic increase in immunosuppressive therapy. Intraoperatively, when doing PPV for retinal detachment, the surgeon should be especially thorough with the extent of membrane peeling and with hemostasis. One last pearl is that injecting cohesive (instead of dispersive) viscoelastic into an RD funnel can be very effective at opening it while preserving the surgeon’s view of the retina.

This summary of Episode 1 of the 2021 VBS meeting is sponsored by

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