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Your unrestricted view into eyecare conferences across the spectrum. Gain exclusive access to Ophthalmology Times Europe® expert-led conference coverage from major meetings throughout the year featuring articles, videos, and insights shared by prominent experts of the ophthalmic community

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A new device for peeling internal limiting membranes (ILMs) and epiretinal membranes (ERMs) provides vitreoretinal surgeons an alternative to forceps during vitreoretinal surgeries.

During the opening day of the American Academy of Ophthalmology’s virtual 2020 annual meeting, Carl Awh, MD, highlighted the Micro-Vacuum Pick (MVP) (Katalyst Surgical). 

Dr. Awh designed the device, which can be used to create a membrane edge, secure the membrane, peel it from the retina, and remove it without removing the instrument from the eye; fluid-air exchange can also be performed when needed.

With all of these capabilities, the number of instrument exchanges decreases, its use may eliminate the need for forceps and scrapers, and it may even cause less trauma to the macula. The device is available with 23-, 25- and 27-gauge shafts.

“The MVP is a multi-function device with active aspiration controlled by a foot pedal, using the active extrusion function of a vitrectomy machine,” said Dr. Awh, who is in private practice at Tennessee Retina in Nashville, TN.

At the distal end of the MVP is smooth primary spatula that is designed to lift membranes but not shred them. The spatula shields the retina from the vacuum port, which is located much closer to the tip than the port of a vitrectomy cutter.

It is small enough to create vacuum holding force but is sufficiently large enough to allow pieces of membranes to be aspirated out of the eye through the lumen of the MVP.

Two micropicks, one on each side of the tip, can be used to create an edge or flap in the membranes, and importantly, this is done with minimal risk of damaging the underlying retina.

Dr. Awh showed surgical videos of the MVP in cases of epiretinal membrane, macular hole, and traction retinal detachment. He used the MVP to perform the fluid-air exchange in the macular hole case, eliminating the need for a separate extrusion cannula.


Dr. Awh has used the MVP in more than 100 cases, the majority of which were performed to treat ERMs or macular holes. 

However, he has also used the MVP for more complicated cases such as diabetic traction detachment, myopic retinal detachment, and proliferative vitreoretinopathy retinal detachment. The 25-gauge model was used in most cases; 3 cases each were performed using the 23- and 27-gauge models.

In only 10 of the 100 cases, an instrument exchange was needed to wipe a fragment of a membrane that clogged the port of the device. No iatrogenic retinal breaks or other complications were observed.

Based on the device’s performance, Dr. Awh highlighted its advantages.

“I find the MVP to be more stable device and less fatiguing, in that there is no need to activate forceps with my hand,” he said. “The device reduces or eliminates the need to remove and wipe forceps. The teasing action used to peel the membranes may transmit less stress to the macula than when peeling the membranes with forceps.”

An expected disadvantage is the need for the surgeon to learn new techniques with a new device, particularly the use of the micropicks to create the initial membrane flap or edge. Also, the MVP may be less effective for peeling very thick or rigid membranes, he explained.

A retrospective outcomes analysis is underway in which the 6-month postoperative outcomes using forceps are being compared with the 6-month outcomes using the MVP following peeling of ILMs and ERMs.

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Dr. Awh is a consultant to and owns stock in Katalyst Surgical. Patents are pending for this device.

During Day 1 of AAO 2020, Carl Awh, MD, discusses the Micro-Vacuum Pick, a device for peeling internal limiting membranes that's providing vitreoretinal surgeons an alternative to forceps during surgeries.


AAO: Micro Vacuum Pick for use during vitreoretinal surgery could be a better mousetrap

Anti-vascular endothelial growth factor therapy (VEGF) performs well for treating retinal arteriolar macroaneurysms (RAM) that are near the fovea including the optic disc and does not cause branch retinal artery occlusion or rupture the RAM as can occur with direct laser photocoagulation, according to J. Fernando Arevalo, MD, PhD. , reported.

Dr. Arevalo highlighted the treatment during a presentation at the American Academy of Ophthalmology’s virtual 2020 annual meeting. He is the Edmund F. and Virginia B. Ball professor and chairman of ophthalmology at Johns Hopkins Bayview Medical Center, Wilmer Eye Institute, Johns Hopkins University, Baltimore, MD.

RAM are fusiform dilatations of the arteriolar system that are characterized by thickening of the arterial walls, Dr. Arevalo explained and pointed that that most of these lesions involute spontaneously but if they do not do so or do regress late, irreversible vision loss is possible from persistent cystoid macular edema, hard exudates, or intraretinal hemorrhages.

Dr. Arevalo and colleagues conducted a retrospective international multicenter study with the hopes of pinpointing the risks and benefits of anti-VEGF therapy for treating RAM and associated visual loss.

“We found that in 32 eyes of 32 patients treated with a mean of 2.7 anti-VEGF injections over a mean of 16.6 months the baseline vision improved over time from 0.97 logarithm of the minimum angle of resolution (logMAR) to 0.53 at 3 months,” he reported.

The concurrent central macular thickness (CMT) improved from the baseline 477 μmmicrons to 305 at 3 months. The mean RAM size was 450 μmmicrons and the mean distance to the fovea was 2,691 μmmicrons.

Ranibizumab (Lucentis, Genentech Inc.) was used to treat 14 patients and bevacizumab (Avastin, Genentech Inc.) in 16 patients. In 2 patients, aflibercept (Eylea, Regeneron Pharmaceuticals) was used in conjunction with bevacizumab in 1 patient and with both ranibizumab and bevacizumab in 1 patient.

One injection was administered in 13 eyes, the rest of the eyes required multiple injections ranging in number from 2 to 13.

Dr. Arevalo reported that the baseline best-corrected VA (BCVA) was significantly (P = 0.02) correlated with RAM size and the distance to the macula. The CMT decreased in size (P <0.001) by 131, 180, and 211 microns at 1, 2, and 3 months, respectively. 

The BCVA improved (P = 0.005) by 0.47 and 0.38 logMAR, respectively, at 2 and 3 months post-injection. Finally, the response to anti-VEGF therapy was correlated with the RAM size (P =0.04) and the distance to the macula (P = 0.009).

In a representative patient, Dr. Arevalo showed the substantial benefit of 1 anti-VEGF injection 3 months later with reduction of exudates and at 9 months normalization of the foveal contour and improved vision.

Based on these results, Dr. Arevalo said the investigators concluded that anti-VEGF therapies improves the VA and decreases the macular edema via their vasoconstrictive effect and a stabilizing effect on the blood retinal barrier while the RAM undergo progressive fibrosis and closure.

In addition, the close proximity of the RAM to the fovea favors anti-VEGF treatment because there are no locally destructive side effects. 

The resolution of perianeurysmal exudates or hemorrhages and gradual obliteration of the RAM seem to occur rapidly with anti-VEGF therapy by avoiding retinal damage from laser photocoagulation, Dr. Arevalo concluded.

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Dr. Arevalo has no financial interest in this subject matter. Intravitreal bevacizumab, ranibizumab, and aflibercept were used off-label in this study.

At AAO 2020, Fernando Arevalo, MD, PhD, details the use of anti-VEGF therapy for the treatment of retinal arteriolar macroaneurysms that are near the fovea.

AAO: Intravitreal anti-VEGF injections for exudative RAM offering an  alternative to laser

Anne L. Coleman, MD, president of the American Academy of Ophthalmology, offers a preview of its virtual 2020 annual meeting. The AAO is rising to meet the challenges of staging a large-scale event in a virtual setting.

Videos

Anne L. Coleman, MD, president of the American Academy of Ophthalmology, offers a preview of its virtual 2020 annual meeting. 

AAO: Bringing high-level content to a virtual audience

, past chief and chair, Department of Ophthalmology, Antwerp University and University Hospital Antwerp, Belgium, expands on her upcoming AAO presentation by providing an overview of her novel technique in performing a risk-free posterior capsulorhexis.

Prof. Marie-José Tassignon, past chief and chair, Department of Ophthalmology, Antwerp University and University Hospital Antwerp, Belgium, expands on her upcoming AAO presentation by providing an overview of her novel technique in performing a risk-free posterior capsulorhexis.

AAO: How not to be afraid of performing a posterior capsulorhexis


Chris Brittain, MBBS, BSc, MBA, MRCOphth, vice president and global head of ophthalmology product development for Genentech, provides an overview of some of the company’s podium presentations from the Port Delivery System with ranibizumab to the novel pipeline molecule, faricimab.

Chris Brittain, MBBS, BSc, MBA, MRCOphth, vice president and global head of ophthalmology product development for Genentech, provides an overview of the company’s podium presentations from the PDS with ranibizumab to faricimab.

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