2023 Wills Eye Conference Presentations: Top Retina Takeaways

The 2023 Wills Eye Conference in Philadelphia showcased 5 hours worth of research from the prestigious hospital’s residents, fellows, and other physicians Thursday, March 9, 2023. The presenters offered insight into new findings on topics as diverse as minimally invasive glaucoma surgeries, conjunctival and iris melanomas, corneal transplantation, intraocular lenses, and retinal surgeries and their complications.

The portion of the day dedicated solely to topics of retinal disease illuminated questions around the severity of loss to follow up during the height of the COVID-19 pandemic, elements of co-management with other ophthalmic subspecialists, issues of health care disparity, advancements in treating epiretinal membrane, and so much more. 

Here, we provide a comprehensive review of the retina portion of poster presentations from that conference and explain the 3 big takeaways the researchers offered.

1. Epiretinal Membranes Are Common After Various Retinal Surgeries

Postoperative epiretinal membranes (ERM) develop for a variety of reasons.¹ It is common after surgeries such as pars plana vitrectomy, with and without scleral buckling, and pneumatic retinopexy.^2,3 Studies presented at the Wills conference describe ERMs after scleral buckling as mild, often remaining at grade 1.² But their frequency doesn’t mean they can’t be predicted. Researchers pointed to large drainage retinotomies as having particularly high likelihood of ERM formation.¹ 

“When we look at risk factors for epiretinal membrane formation, we found that the two quantitative factors we were able to measure were statistically significant; larger area of drainage retinotomy and a larger area or peripheral retinal pathology were both risk factors for epiretinal membrane formation,” explained presenter Asad F. Durrani, MD. He said they were also able to confirm some of the classic risk factors such as large extent of retinal detachment, vitreous hemorrhage, use of silicone oil tamponade, and any redetachment within 6 months. 

However, the mere presence of drainage retinotomy does not appear to increase ERM formation risk, Dr Durrani explained. Neither does the drainage retinotomy location or distance from the macula.

“We feel that this is because larger retinotomies are more likely to facilitate the cellular proliferative process that is the cause of epiretinal membrane formation,” Dr Durrani said. “Creation of drainage retinotomies at any location is acceptable as long as the size is kept as small as possible to accomplish the goal of surgery, which is flattening the retina.” 

Another report, presented by Wills Eye fellow Hana A. Mansour, MD, detailed a retrospective review of optical coherence tomography (OCT) findings in patients who developed ERM after scleral buckle. That report shows 171 of 1088 eyes (15.72%) that were treated with scleral buckle developed subsequent ERM, with 147 meeting inclusion criteria. At diagnosis, 108 (59%) eyes had grade 1 ERM, 13 (14%) grade 2, 16 (25%) grade 3 and 3 (2%) grade 4. 

While 125 eyes (85.03%) were observed, 22 (14.97%) required ERM peel; and 10 (45.45%) of them had evidence of ERM after peel, according to the presentation. At the final visit, 109 (83.85%) eyes had grade 1 ERM, 8 (6.15%) grade 2, 10 (7.69%) grade 3 and 3 (2.31%) grade 4.²

“We noticed that when ERM was diagnosed earlier on after buckling, around 3 months, those eyes were more likely to get membrane peel. Whereas, when ERM was diagnosed after more than a year after scleral buckle, those eyes were just observed. Also, the eyes that had worse visual acuity at time of ERM diagnosis were more likely to get membrane peel,” she said. The ERMs in the observed eyes remained fairly mild at 3, 6, and 12 months after buckling, she reported, with visual acuity and ERM stage remaining stable.²

Pneumatic retinopexy — a minimally invasive outpatient procedure for retinal detachment that involves injecting a gas bubble into the eye to help the retina readhere — can also result in ERM, explained Robert M. Abishek, BA. In the research he presented, the team established that 161 of 728 (22.12%) eyes developed ERM after pneumatic retinopexy. Of the 120 eyes that met inclusion criteria, 72% had stage 1 ERM, and most never progressed in the course of the study — more than 12 months. Most eyes were managed by observation alone.³

2. Some Severe Complications Are Avoidable

As researchers better target the likelihood of complications such as hypotony, vitreous hemorrhage, and macular edema, surgeons can better tailor their choices for each patient to maximize the odds of success. 

One such study, presented at the 2023 Wills Eye Conference by Anand D. Gopal, MD, explained that patients who receive a dexamethasone (DEX) implant to manage postoperative macular edema appear less likely to develop hypotony than those who are treated with intravitreal triamcinolone (IVT). In that research, 75 eyes implanted with the DEX device and 72 eyes given triamcinolone injections were followed for at least 3 months. The rates of transient hypotony per eye and injection were significantly higher in the DEX group compared with the IVT group (P =.039 and P <.001, respectively). The researchers noted no significant between-group differences in ocular hypertension, vitreous hemorrhage, or retinal detachment.⁴

Another study analyzed the risk for patients with neovascular glaucoma to require surgery or to lose vision despite having undergone treatment with anti vascular endothelial growth factor (VEGF) injections. “We wanted to figure out what were the factors associated with uncontrolled glaucoma, which we defined as either going on to receive glaucoma surgery, or reaching [no light perception (NLP)] vision,” explained presenter Erik Massenzio, MD. The 301-patient cohort study shows 6 particular characteristics that could put individuals with neovascular glaucoma at an elevated risk for requiring glaucoma surgery despite anti-VEGF treatment: 

1. Having an intraocular pressure (IOP) higher than 35 mm Hg (P <.001), 
2. Using 2 or more topical glaucoma medications (P =.003), 
3. Presenting with worse than 20/100 vision (P =.024)
4. Presenting with proliferative diabetic retinopathy (PDR) (P =.001), 
5. Eye pain (P =.010), 
6. New patient status (P =.015) at the time of NVG diagnosis.

However, Dr Massenzio explained that panretinal photocoagulation (PRP) may be an option for patients with these characteristics. “Treatment with PRP was found to be very significant and showed a protective effect for uncontrolled neovascular glaucoma.” However, PRP is not a perfect solution, as research shows it can lead to peripheral restriction, decreased contrast sensitivity and decreased color vision.⁵

“It’s important to pick which patients should receive PRP. Our study, unlike previous studies, shows that there may be a role for anti-VEGF monotherapy over the addition of PRP to anti-VEGF injections,” Dr Massenzio said. “In all patients there was a treatment effect with PRP plus anti-VEGF injections, but in patients without media opacities who were eligible for PRP, treatment effect went away” and became insignificant. 

Research into the use of PPV for patients with vitreous hemorrhage (VH) associated with retinal vein occlusion (RVO) also warns that some pre-existing and postoperative complications can limit visual success after the procedure. Kristine Wang explained that “A recent study comparing the outcomes of vitrectomy vs non-vitrectomy treatments for VH associated with central RVO showed better outcomes in the vitrectomy group than the non-vitrectomy group. However, the rates of postoperative complications after PPV and their influence on visual outcomes has not yet been studied.”⁶

The study’s results show that, while most eyes (more than 90%) require only 1 surgery and 75% or eyes achieved visual improvement of 3 lines or more at 6 months, “worse final visual acuity was significantly associated with older age, concurrent neovascular glaucoma, central (rather than branch) RVO, worse preoperative visual acuity, postoperative newly developed neovascular glaucoma, and postoperative retinal detachment,” Ms Wang said. “However, of note, the duration of vitreous hemorrhage was not associated with postoperative vision.”⁶

That study also shows that the presence of tamponade, or a history of anti-VEGF injections or PRP, did not prevent postoperative recurrent vitreous hemorrhage. 

3. Patient Circumstances Can Inform Clinicians, Or Limit Outcomes  

A vital tool in achieving successful outcomes is understanding the patient experience. Surgeons are great at listening to their patients’ individual needs. But, today, the internet is offering so many tools to listen to patients on a more macro level. Several presentations at the 2023 Wills Eye Conference demonstrate how big data can improve patient care.

Consider the presentation from Taku Wakabayashi, MD, PhD, titled “Google Search Trends to Assess Public Interest and Concern Related to Vuity™ for Presbyopia.” Vuity (1.25% pilocarpine HCl ophthalmic solution, Allergan) is a prescription drop designed to address presbyopia. Google Trends, a publicly available tool for analyzing Google search data, shows that patients certainly have responded to advertising campaigns around the presbyopia drop, but also that patients have some concerns. The search volume for Vuity and related topics shows a peak in March and April 2022, “likely influenced by the direct-to-consumer advertising in the form of television commercials by Allergan which were initiated on March 8, 2022,” Dr Wakabayashi said. But, through their Google searches, patients have expressed some knowledge and concern about the drug’s potential side effects as “Vuity side effects” and “Vuity retinal detachment” search volume also shot up around the same time.⁷   

Further investigation shows posts on social media sites Reddit and Facebook where patients expressed concerns about retinal detachment.⁷ 

Another study shows that pediatric retina specialists may not be available to some vulnerable communities, including those living below the poverty line, families with lower education levels, and those in more rural settings. However, the same research shows that those living in counties with higher rates of very-low birthweight neonates had shorter travel times. 

“Visual impairment itself incurs a hefty economic burden on families and communities. Future efforts to improve access to care should consider focusing on these vulnerable populations,” said presenter Lucy V. Cobbs, MD, a third year resident at Wills Eye. “The first step toward improving access to care should be creating a publicly available comprehensive database of all vitreoretinal specialists who care for children in some capacity.”⁸

The retina-focused research at the 2023 Wills Eye Conference offered lessons any surgeon can benefit from. These new techniques and approaches are bound to influence practicing physicians as well as medical students making their way into ophthalmology.