Day 2 of the 17th Congress of the Asia-Pacific Vitreo-retina Society (APVRS 2024) was a showcase of intellectual brilliance, as the prestigious Constable, Dennis Lam and Richard Fan Award lectures took center stage. From cutting-edge surgical innovations to the transformative role of artificial intelligence, these lectures brought an electrifying mix of clinical expertise and visionary ideas to the audience.
In a series of thought-provoking talks, the three awardees shared their groundbreaking work, offering deep insights into some of the most pressing challenges and opportunities in retinal care. Dr. Shida Chen (China), this year’s Constable Award winner, tackled the complexities of myopic macular holes with a blend of innovative surgical techniques and sharp clinical acumen. Dennis Lam Awardee Prof. Paisan Ruamviboonsuk (Thailand) explored the nuanced integration of artificial intelligence (AI) into healthcare systems, highlighting both the promise and pitfalls of this rapidly evolving technology. Meanwhile, Richard Fan Awardee Prof. Andrew Chang (Australia) captivated the audience with a masterful journey through the evolution of vitreoretinal surgery for age-related macular degeneration (AMD), from high-risk early procedures to today’s cutting-edge innovations. Together, these luminaries brought the perfect blend of science, technology and vision to the APVRS stage.
An innovative technique for myopic MH
Treating myopic macular holes (MH) is a task fraught with complexity, particularly in patients with high myopia. Setting the stage for a discussion rich with both urgency and insight, Dr. Shida Chen (China) posed a compelling question: “Would you believe that high myopia will become the leading cause of blindness in the world by the year 2050?” With this stark prediction, he underscored the critical need to refine and advance treatment options.
Dr. Chen began by unraveling the intricate pathophysiology of myopic MH, describing the mechanical forces at play with remarkable clarity. He explained the interplay of inward tangential traction from epiretinal membranes, outward posterior traction from staphyloma and the pivotal role of the internal limiting membrane (ILM). This dynamic tension, he noted, lies at the heart of the challenge in treating these cases.
On the surgical front, Dr. Chen first explored pars plana vitrectomy (PPV), the widely adopted technique for relieving tangential traction by removing the vitreous and peeling the ILM. While effective in most cases, he acknowledged its limitations in countering the backward traction exerted by posterior staphyloma. As a solution, he highlighted the inverted ILM flap technique, which achieves an impressive 80-90% closure rate for larger macular holes, demonstrating its potential in overcoming some of PPV’s shortcomings.1
Turning to a more traditional yet still relevant approach, Dr. Chen revisited macular buckling (MB), a technique designed to counteract the outward pull of posterior staphyloma. Building on this foundation, he unveiled a novel combined technique—integrating PPV with MB—designed to tackle the multifactorial nature of myopic MH. “MB combined with vitrectomy is an effective solution for myopic macular hole,” he stated, bolstering his claim with clinical trial data that demonstrated favorable outcomes.2
From AI innovation to practical implementation
Artificial intelligence holds both immense promise and formidable challenges in retinal care, particularly with its integration into national healthcare systems. Prof. Paisan Ruamviboonsuk (Thailand) delved into this complex landscape, spotlighting the gap between AI’s theoretical potential and its real-world application.
“The parameters for assessing AI development and deployment are different,” he began, explaining that while sensitivity and specificity are key during development, practical deployment depends more on positive and negative predictive values which are influenced by disease prevalence in the target population.
Bridging the divide between development and implementation, Prof. Ruamviboonsik emphasized the human element. “AI literacy is essential for both healthcare providers and patients,” he remarked, stressing that education is key to unlocking the technology’s transformative power. Without a foundational understanding of AI, stakeholders may struggle to harness its full capabilities. Complementing this, he underscored the critical role of governance in ensuring equitable access. “AI governance is a framework ensuring AI equity, or access of AI, for all,” he noted, advocating for policies that promote fairness and inclusivity.
On the technical front, Prof. Ruamviboonsuk highlighted the need for standardized data formats to streamline AI integration. “A standardized file format may enhance seamless deployment, with data safety and security of AI,” he explained, linking interoperability to both operational effectiveness and patient trust.
As his lecture drew to a close, Prof. Ruamviboonsuk delivered a critical reminder: AI models must be customized for the communities they aim to serve. “AI models should be tested and tailored to specific target populations before deployment,” he urged, framing this as essential to achieving meaningful, equitable outcomes.
Vitreoretinal surgery’s evolving role
With decades of innovation as his canvas, Prof. Andrew Chang (Australia) painted a vivid picture of the evolution of vitreoretinal surgery for macular degeneration. From its challenging beginnings to the forefront of modern advancements, he charted a journey marked by resilience, breakthroughs and transformative change.
Reflecting on the field’s early days, Prof. Chang recalled the high-risk procedures that once defined AMD treatment, such as macular translocation and submacular surgery—grueling endeavors requiring immense precision and carrying significant risks. Then came the advent of anti-VEGF therapy, which revolutionized AMD care. “Anti-VEGF descended upon us, and the world for a retinal surgeon became different,” he remarked, capturing the seismic shift that reshaped the landscape of retinal surgery.
Turning to subretinal hemorrhages, a common complication of AMD, Prof. Chang highlighted how surgical advancements have made these cases less daunting. Techniques such as intravitreal gas injections and tissue plasminogen activator (tPA) have emerged as first-line treatments, reducing the invasiveness of hemorrhage management. “Intravitreal gas and tPA, vitrectomy and anti-VEGF remain key components in the management of these subretinal bleeds,” he explained, adding that heavy liquids have proven invaluable during surgeries, allowing for controlled and effective blood displacement without compromising surrounding tissue.
Prof. Chang then gazed into the future, exploring the potential of innovations like the Port Delivery System (Susvimo®; Roche, Basel, Switzerland). This device offers sustained-release ranibizumab (Lucentis®; Roche) addressing a significant challenge in AMD care. “The real challenge for us is not that anti-VEGFs aren’t effective… but how do we reduce the burden?” he asked, underscoring how PDS could alleviate the demands of frequent treatments for both patients and providers.
As his lecture drew to a close, Prof. Chang offered a glimpse into future advancements, including gene therapy and next-generation vitreous substitutes.
Editor’s Note: Reporting for this story took place during the 17th Congress of the Asia-Pacific Vitreo-retina Society (APVRS 2024) from 22-24 November in Singapore.
References
- Silva N, Ferreira A, Nawrocka Vel Michalewska ZA, Meireles A. Inverted Internal Limiting Membrane Flap Technique: Is It the Best Option for Macular Holes? Clin Ophthalmol. 2021;15:3295-3303.
- Luo N, Chen S, Zhao X, et al. Macular buckling combined with vitrectomy and inverted internal limiting membrane flap technique for macular holes with macular retinoschisis without retinal detachment in high myopia. Retina. 2022;42(11):2051-2058.
