Advances in Surgery for Vitreoretinal Disease.

Abstract

T he convergence of innovation in diagnostic imaging, molecular medicine, biotherapeutics, and biomaterials have resulted in new and expanded indications for the management of the vitreoretinal disease. Evolving beyond the treatment of patho-anatomy alone, vitreoretinal surgery now encompasses a variety of expanding roles that include tissue transplantation, techniques that extend therapeutic effects, and, in the case of gene, stem cell, or cell-based therapies, encompass treatments that may permanently cure disease. Optical coherence tomography angiography (OCT-A) is emerging as a noninvasive technique that provides both structural and physiologic information about the retino-choroidal vascular plexuses. The ability to quantitatively image the retina and choroidal vasculature as independent tissues has led to new insights into the pathophysiology of macular choroidal neovascularization. Bacherini et al reviewed the use of OCT-A in vascular and nonvascular retinal disease. In diabetes and venous occlusive diseases, assessment of perfusion and ischemic tissues holds promise for developing new biomarkers for management. OCT-A has also demonstrated the ability to detect preclinical changes in vasculature in nonvascular macular conditions including epiretinal membrane, macular hole, and vitreoretinal interface disorders including retinal detachment. These findings help to explain the heterogeneity of visual acuity outcomes after anatomically successful surgeries and may become a predictive biomarker for visual improvement after vitreoretinal surgery. The use of OCT-A in diabetic retinopathy (DR) is further examined by Borrelli et al. Long recognized as a progressive microvasculopathy, the clinical assessment of diabetic pathophysiology depended primarily on ophthalmoscopy and fluorescein angiography to image inner retinal circulation. Indocyanine green angiography has enjoyed limited use in select choroidal vascular conditions, but OCT-A has permitted the identification of distinct superficial, intermediate, and deep capillary plexuses of the retina. The middle and deep capillary plexus comprise the deep vascular complex and together, define the vascular anatomy of the foveal avascular zone. The ability to use macular, threedimensional, and wide-field OCT-A to quantify retinal capillary perfusion, ischemia, and clinical signs of progression has yielded insights that have helped clarify the natural history and pathoanatomy of DR. The findings that microaneurysms are most likely to reside in the inner nuclear layer, that IRMA (intraretinal microvascular abnormalities) do not change with panretinal laser and may represent vascular remodeling, and that progressive choriocapillary hypoperfusion may impact vision through photoreceptor dysfunction, have potential implications for the management of DR. The increasing prevalence of myopia in the Asia-Pacific is another topic of growing concern. Parolini et al shared a new perspective on the classification of myopic traction maculopathy (MTM). Their work reviews the historical perspectives on the prior classification of vision-threatening complications including myopic macular hole and macular detachment. Parolini et al proposed a novel classification system that includes nomenclature, pathogenesis, and prognosis of MTM. They propose an MTM staging system as a clinical system for the management of MTM alone. It is differentiated from established classifications some of which include all aspects of myopic maculopathy that include macular atrophy, traction, and neovascularization. The review of the outcomes, literature for surgical management of MTM and the analysis of structural changes of progressive myopic macular traction is the basis for recommended guidelines for management. Vitrectomy was recommended for stages where tangential macular forces are primary and macular buckling for conditions worsened by axial elongation and macular staphyloma. Recognition of the vitreoretinal interface has been critical to the understanding of the pathoanatomy and the success of nearly all indications for vitreoretinal surgery. Complex retinal detachment, macular hole, macular pucker, and