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125 October 2015 EW MEETING REPORTER surface—retinoschisis has a smooth surface while detachments have a corrugated surface. In addition, schisis usually has no hemorrhage or pigment and reacts to photocoag- ulation. Schisis is more common in hyperopes than myopes and is often bilateral. To manage retinoschisis, start by observing the patient, Dr. Weng said. Monitor the patient regularly and only operate on symptomatic, progressive cases that are likely to lead to a detachment. Editors' note: Dr. Weng has no finan- cial interests related to her comments. Intraoperative aberrometry options There are currently 2 intraoperative aberrometry systems available, and Richard Tipperman, MD, Bala Cynwyd, Pa., highlighted both the HOLOS IntraOp system (Clarity Medical Systems, Pleasanton, Calif.) and the ORA with VerifEye (Alcon, Fort Worth, Texas). Best practices for managing diabetic retinopathy According to Steve Charles, MD, Memphis, there is only one way to effectively treat diabetic macular edema: intravitreal injections of vascular endothelial growth factor (VEGF) inhibitors. During the "Retina Review" session, Dr. Charles told attendees to forget about using the grid laser to treat diabetic retinopathy and use VEGF inhibitors as a first line treatment. Never use steroids to treat DME, he added, because steroid effi- cacy and treatment effect are linked —the more effective a steroid is, the more it causes cataracts and glauco- ma. Rather than using a sequential treatment method, such as starting with a steroid and moving on to an anti-VEGF agent, use anti-VEGFs as soon as the patient comes in. "Don't delay using anti-VEGF therapies," Dr. Charles said. "Hit them the first day they come in with a drug that works." By decreasing vascular permea- bility and inhibiting angiogenesis, VEGF inhibitors represent the new gold standard for diabetic retinopa- thy care. "Name a drug that has zero side effects, zero tachyphylaxis, and zero allergic reactions," Dr. Charles said. "You can't—except for anti-VEGFs." For that and other reasons, Dr. Charles believes that besides cataract surgery, anti-VEGF agents represent the biggest advance made in oph- thalmology in the last 100 years. VEGF inhibitors may be the best treatment for DME, but which anti-VEGF agent is best? Dr. Charles described how the 3 available op- tions—Eylea (aflibercept, Regeneron Pharmaceuticals, Tarrytown, N.Y.), Lucentis (ranibizumab, Genentech, South San Francisco), and Avastin (Bevacizumab, Genentech) differ from one another in structure and efficacy. Eylea is a recombinant fusion protein of key domains of the VEGF receptor that binds to all VEGF isoforms as well as placental growth factor. Lucentis and Avastin are anti- VEGF monoclonal antibody frag- ments, but Lucentis has 25 times the molecular affinity for VEGF-A. After reviewing the relevant studies, Dr. Charles concluded that Eylea is the most effective treatment, followed by Lucentis and then Avastin. Editors' note: Dr. Charles has no finan- cial interests related to his comments. How to manage peripheral retinal disease With the great strides we've made in treating macular disease, it's easy to forget about the peripheral retina, said Christina Weng, MD, Hous- ton. The far periphery of the retina is susceptive to pathology because that's where the vitreous base is most adherent and straddles the ora serrata, Dr. Weng said. She dis- cussed 3 common peripheral retinal findings—retinoschisis, operculated tears, and lattice degeneration—and how best to manage them. Retinoschisis is a splitting of the neurosensory retinal layers. Most pa- tients are asymptomatic, but it can lead to holes in the inner or outer wall. Retinal detachments can mim- ic retinoschisis, so to differentiate between the two, look at the retinal Ophthalmic Symposium View videos from Sunday at COS 2015: EWrePlay.org Douglas D. Koch, MD, compares suture fixation to haptic gluing for attaching the IOL to the sclera. View videos from Sunday at COS 2015: EWrePlay.org Christina Weng, MD, discusses diagnosis and management of non-neovascular AMD. continued on page 126

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