Experts grappled with contemporary retinal topics from firstline treatments in PDR, CSC and myopic tractional maculopathy to OCT-A.
The sun was hot outside the Yashobhoomi Convention Centre for the 40th Congress of the Asia-Pacific Academy of Ophthalmology (APAO 2025), held in conjunction with the 83rd Annual Conference of the All India Ophthalmological Society (AIOC 2025)—but the vibe inside was hotter for a series of debates in surgical and medical retina on the Congress’ second day.
With the Delhi sun pushing 40°C, APAO-AIOC attendees found little shelter from the heat as some of the world’s foremost retina experts jousted over some of the most heated controversies in modern retinal medicine for a session co-hosted with the American Academy of Ophthalmology (AAO).
Structured in pairs of talks, names like Prof. Kyoko Ohno-Matsui (Japan), Prof. Colin Tan (Singapore), Prof. Srinivas Sadda (India) took opposite sides in a variety of topics: optical coherence tomography angiography (OCT-A)’s role in retinal disease, firstline therapies for myopic tractional maculopathy, central serous chorioretinopathy (CSCR) and proliferative diabetic retinopathy, and the role of anti-VEGF in neovascular age-related macular degeneration (nAMD)
Debate 1: OCT Angiography for Retinal Diseases
Key Question: Should OCT-A come into routine clinical use for retinal diseases?
Dr. Muna Bhende (India): YES
Dr. Bhende argued for routine clinical use of optical coherence tomography angiography (OCT-A), noting that it “studies the vasculature, both normal and abnormal, and also gives you a corresponding B-scan.”
She emphasized the practical advantages: “It’s quick, noninvasive and most commercial instruments now have standardized protocols. It’s easily repeatable if you feel you’ve missed something, and it’s very practical for frequent monitoring.”
Dr. Srivinas Sadda (India): NO
Dr. Sadda acknowledged OCTA’s usefulness but questioned its routine necessity: “The criteria for a technology to be used routinely is that it has to be essential in management to improve outcomes, save us time or at least reduce cost.”
He pointed out that “there must be wonderful level 1 clinical trial data that shows using OCT-A improves outcomes for patients—and when we look at the literature for evidence, we find there’s actually none.” He concluded that OCT-A is “definitely a nice to have” but not essential for routine practice.
Debate 2: Duelling surgeries for myopic tractional maculopathy
Key Question: Should retinal surgeons go with macular buckles or vitrectomies for myopic tractional maculopathy
Dr. Kyoko Ohno-Matsui (Japan): VITRECTOMY
“Wide field OCT often reveals that vitreous traction of retinal vessels away from the macula is a primary cause of retinal schisis,” she said in defense of vitrectomies.
She specifically cautioned against macular buckle procedures, noting they “may exacerbate mechanical damage to the optic nerve” and carry “risks of developing macular artery injury and injuring penetrating vessels.”
Dr. Simon Szeto (Hong Kong): MACULAR BUCKLE
Dr. Szeto went on the attack from the beginning in his turn at the podium. “Vitrectomy and ILM peeling has several inherent limitations when treating MTM (myopic tractual maculopathy),” he said. “It may contribute to myopic macular atrophy, postoperative macular hole formation and has a low success rate in high myopia-associated macular holes.”
He focused mainly on the virtues of the surgery vis-a-vis its proven track record of patient outcomes and treatment of underlying MTM disease mechanisms. “Macular buckle surgery has good efficacy in MTM by improving best-corrected visual acuity and reducing axial length, which may counter the progressive nature of MTM.”
Debate 3: There, here and now in nAMD
Key Question: How can ophthalmologists do right by their patients in the age of anti-VEGF?
Dr. Ramachandran Nair (India): TREAT-AND-EXTEND
It’s all about treat-and-extend regimens with anti-VEGF for nAMD, Dr. Nair argued. “PRN is more likely to lead to undertreatment in the real world,” he said, and lacks “a well-defined exit strategy.”
Dr. Colin Tan (Singapore): AS NEEDED, OR pro re nata (PRN)
Dr. Tan believes in the practical merits of PRN treatment, primarily citing cost considerations. “In many countries, patients either pay out of pocket or have some co-pay involved. For these patients, every dose of injection carries a cost.”
He challenged the notion that treat-and-extend requires fewer visits. “The difference in terms of the mean number of visits… is not that big a difference,” he argued.
He also emphasized patient preferences as a key argument for PRN. “Many patients dread injections, and they’re in fear of requiring injections. If you tell them that ‘I don’t need to inject you today,’ many of them express a great deal of relief.”
Debate 4: Getting Serious about Central Serous Chorioretinopathy
Key Question: What’s the best firstline option for CSCR?
Dr. Lihteh Wu (Costa Rica): MICROPULSE LASER
Dr. Wu advocated for yellow subthreshold laser therapy, presenting data from a retrospective comparative study (authored, among others, by nefarious opponent Dr. Jose Roca (Peru)) of 92 eyes treated with subthreshold laser versus 67 eyes treated with half-dose PDT.1
“The yellow micropulse laser has a more beneficial effect in visual acuity than half-dose PDT,” he noted, while conceding that both treatments effectively restored macular anatomy in chronic CSCR cases.
Dr. Jose Roca (Peru): PHOTODYNAMIC THERAPY
Dr. Roca countered with evidence supporting photodynamic therapy (PDT), citing the PLACE clinical trial and arguing for PDT’s superior anatomical results: “At the first evaluation visit, 51 percent of half-dose PDT treated patients showed complete resolution of subretinal fluid compared to only 13.8 percent with subthreshold micropulse laser,” he said.2
He also gave a nod to PDT’s positive effects on functional vision gains. “PDT treated patients showed a significant increase in best-corrected visual acuity and a significantly higher increase in retinal sensitivity,” though both treatments showed similar improvements in vision-related quality of life.
Debate 5: The first line in proliferative diabetic retinopathy?
Key Question: What should we start with in proliferative diabetic retinopathy (PDR)?
Dr. Maria Berrocal (Puerto Rico): LASER
Dr. Berrocal highlighted concerns with anti-VEGF therapy for PDR, highlighting the treatment burden. “Anti-VEGF does not reverse neovascularization, it masks it. If you stop the anti-VEGF, the same neovascular vessels come back.”
She also reached deep in her bag with compelling economic data from APAO-AIOC 2025’s host country. “In India with 180 million diabetics… we would need to treat patients with PDR with over 9 million injections yearly. That would be 760,000 injections monthly—enough to just bankrupt any health system.”
Dr. Jay Sheth (India): ANTI-VEGF
Dr. Sheth defended anti-VEGF therapy as targeting “the root cause of the entire disease process.”
He cited Protocol S data in his defense.”Anti-VEGF therapy can help achieve non-inferior visual outcomes compared to PRP treatment,” he said, with “lower incidence of vision-threatening DME, fewer cases of vitrectomy needed, and significantly less loss of peripheral vision.” On treatment burden, he noted that “from the second year onwards, only an average of 2.5 to 3 injections were needed.”
Editor’s Note: Reporting for this story took place during the 40th Congress of the Asia-Pacific Academy of Ophthalmology (APAO 2025), being held in conjunction with the 83rd Annual Conference of the All India Ophthalmological Society (AIOC 2025) from 3-6 April in New Delhi, India.
References
- Roca JA, Wu L, Fromow-Guerra J, et al. Yellow (577 nm) micropulse laser versus half-dose verteporfin photodynamic therapy in eyes with chronic central serous chorioretinopathy: results of the Pan-American Collaborative Retina Study (PACORES) Group. Br J Ophthalmol. 2018;102(12):1696-1700.
- van Dijk EHC, Fauser S, Breukink MB, et al. Half-Dose Photodynamic Therapy versus High-Density Subthreshold Micropulse Laser Treatment in Patients with Chronic Central Serous Chorioretinopathy: The PLACE Trial. Ophthalmology. 2018;125(10):1547-1555.
