AAO 2024 saw authors from the AAO’s Ophthalmic Technology Assessment retina panel presenting their findings summarizing topline data—and valuable tips—on a variety of retinal disease, including central serous chorioretinopathy and telemedicine for diabetic retinopathy.
Select retinal panelists from the American Academy of Ophthalmology’s Ophthalmic Technology Assessment (OTA) Committee came loaded with practical pearls for attendees of a Day 3 session at the 128th Annual Meeting of the American Academy of Ophthalmology (AAO 2024) in Chicago.
The purpose of the Committee is to establish consensus on procedures, drugs and diagnostic and screening tests for both safety and effectiveness. The resultant papers are published in the Academy’s journal, Ophthalmology, to help guide clinicians with aggregated up-to-date information to guide decision making.
A selection of these papers were summarized at an AAO 2024 Day 3 session, and we’re running down the key findings here.
Uveitic macular edema
Dr. Justine Smith (Australia) began with her summary of the treatment landscape in non-infectious uveitic macular edema. The central question of her OTA report dealt with the effectiveness and safety of peri- and intraocular corticosteroid therapies for patients with the disease.
Dr. Smith’s assessment keyed in on 23 studies looking at five different steroid treatments: periocular, suprachoroidal and intravitreal triamcinolone injection, intravitreal dexamethasone, and intravitreal fluocinolone acetonide implant/insert.
One key study that Dr. Smith highlighted was one comparing three (periocular triamcinolone vs. intravitreal triamcinolone vs. intravitreal dexamethasone) of the modalities at once—the lone comparator study that she included in her OTA.1
“This study provided level one evidence that all treatments were effective for macular edema,” she said. “Intravitreal was more effective than periocular, and it was more likely to be complicated by intraocular pressure elevation.”
The findings of this paper largely echoed her final conclusions, summarized below.
Top pearls and takeaways for non-infectious uveitic macular edema
- All five therapies were effective
- Adverse events were largely centered around cataract and IOP elevation
- Intravitreal therapies showed greater improvements over periocular ones, but carried a higher risk of IOP elevation
- Product information is paramount to treatment planning
Central serous chorioretinopathy
Dr. Leo Kim (USA) talked about his OTA on central serous chorioretinopathy (CSCR). His assessment dealt with both acute and chronic CSCR, and evaluated photodynamic therapy (PDT), intravitreal anti-VEGF therapy and systemic therapies.
Intravitreal therapies explored were ranibizumab in acute CSCR and bevacizumab in chronic CSCR. For acute CSCR, systemic treatment of H. pylori using combination therapy with omeprazole, clarithromycin and amoxicillin was looked at; for chronic CSCR, the effect of systemic mineralocorticoid antagonism with eplerenone was scrutinized.
The main point that Dr. Kim made, and that he himself learned from his own investigation, was that acute CSCR cases resolve spontaneously. He also called for larger studies, further investigation into H. pylori infection and new intravitreal agents, and the use of new imaging modalities like OCT angiography and wide-field imaging.
Top pearls and takeaways for CSCR
- Many acute CSCR cases resolve spontaneously
- Half-dose PDT has the best evidence for anatomic improvement
- Intravitreal and systemic therapies had little support
- Strong evidence against mineralocorticoid antagonism with eplerenone in chronic CSCR
Nutritional supplements in retinitis pigmentosa
In one of the more straightforward presentations of the symposium, Dr. Nieraj Jain (USA) spoke on the merits—or lack thereof—of nutritional supplements in retinitis pigmentosa (RP).
Dr. Jain began the presentation with a personal anecdote—a friend messaged him with a rudimentary text document list of vitamins for RP. The friend was asking about the list, thinking that Dr. Jain was the original sender.
But he wasn’t, and this underscores one of the main problems with nutritional supplements in medicine—the general word-of-mouth recommendations, unregulated nature of their use and supported by difficult-to-pin-down, often inconclusive evidence—making it difficult to assess their true efficacy and safety.
“We need some clarity [with supplements],” Dr. Jain said. “And I think with the team here, we did a really deep dive in the literature—and as far as I know, this is the first time the Academy is endorsing a statement on dietary supplements for RP.”
As for the statement itself, it was unequivocally negative. After examining data on high-dose vitamin E, lutein and zeaxanthin, docosahexaenoic acid, vitamin A, there was no quality evidence supporting dietary supplements in RP.
Top pearls and takeaways for supplements in RP
- Current evidence does not support the effectiveness of dietary supplements in RP.
- Some data could suggest possible efficacy, but these data were secondary outcomes, subgroups, post-hoc analyses or presented problematic interpretations
Teleretinal screening for diabetic retinopathy
The final presentation of the day belonged to Dr. Christina Weng (USA), who spoke on a topic of critical importance: the viability of telemedicine in diabetic retinopathy (DR).
This is a topic near and dear to her heart, she said, because DR is still the leading cause of blindness among working-age adults in the United States. And according to Dr. Weng, this OTA was especially important to her because of the difficulties persuading policy makers to invest in loss-making teleretinal screening programs.
These programs put retinal cameras closer to low-resource or difficult-to-reach patients, allowing grading to be done remotely—thereby removing the bottleneck of needing increasingly scarce retinal specialists to screen for disease.
The good news, though, is that Dr. Weng’s OTA found overwhelming benefit for these teleretinal programs. She mentioned a case involving a 39-year-old Hispanic father of two with no discernable vision loss, whose diabetic retinopathy was identified early after a visit to a primary care physician.
“He’s doing really well today, his vision is excellent,” Dr. Weng said “This is a prime example of one of the thousands of people that I feel have been saved as a result of teleretinal screening.”
Top pearls and takeaways for teleretinal screening for diabetic retinopathy
- Teleretinal screening for DR increases capacity to screen large populations
- This method is cost-effective, patient friendly and improves access to care and compliance, preventing vision loss
- Post-screening follow-up remains a challenge
- Financial sustainability is an ongoing concern
- Image quality and standardization remains a concern with detection capabilities
- Teleretina is not a replacement for ophthalmologists, but is an adjunctive technology becoming increasingly critical with capacity constraints
Editor’s Note: Reporting for this story took place during the 128th Annual Meeting of the American Academy of Ophthalmology (AAO 2024) from 18-21 October in Chicago, Illinois, USA.
Reference
- Smith JR, Thorne JE, Flaxel CJ, et al. Treatment of Noninfectious Uveitic Macular Edema with Periocular and Intraocular Corticosteroid Therapies: A Report by the American Academy of Ophthalmology. Ophthalmology. 2024 ;131(9):1107-1120.
