Eyeworld

173 April 2017 EW MEETING REPORTER way; meanwhile, swept-source OCT now allows surgeons to check the macula to see whether it has closed even just a few hours after surgery, potentially shortening the neces- sary duration of face-down postur- ing—which is "both unpleasant and probably unnecessary in the great majority of cases," he said. "The mean duration of the prone positioning of 8.4 days may be too long for modern macular hole surgery," he said. Following swept source-OCT assessment, the duration of prone positioning was 1.8 ± 2.5 days. "Once closed, risk of reopening is very low," he added. Proceeding to discuss refractory macular hole, Dr. Lam said that a size over 400 μm and chronicity over 1 year are poor prognostic factors. He described adjuncts: laser to the base of the macular hole, laser to the macular hole rim, internal limiting membrane flap, and lens capsule flap. Meanwhile, the conventional view of macula-off retinal detach- ment is that the condition always has a poor outcome. However, Dr. green, infracyanine green, and even the relatively benign Brilliant Blue G have some degree of toxicity and are not entirely safe. The traditional method of treating macular holes, Dr. Lam said, includes posturing—having the pa- tient rest in a face-down posture for at least a week. This latter practice, he said, first proposed by Kelly and Wendel in 1991, lacks controlled trials and is a great inconvenience to the patient. More recently, studies propose shortened durations, with reports claiming macular hole closure as early as 3 hours postop and success even without posturing. Posturing is less important, Dr. Lam said, because surface tension is more important than buoyancy in macular hole flattening closure. The surgeon only needs to ensure that the gas bubble remains in contact with the macular hole, so Dr. Lam recommended using a larger gas bubble, performing vitrectomy and gas–fluid exchange as completely as possible, and avoiding the supine position. According to Dr. Lam, holes less than 400 μm are likely to close any- professionals and other resources. This will need a systematic approach that integrates the key elements in partnership with patients, the community, and health players to transform healthcare delivery. At the same plenary ses- sion, Dennis Lam, MD, Hong Kong, provided "An Update on Manag- ing Refractory Macular Hole and Macula-Off Retinal Detachment" as recipient of the Singapore National Eye Centre's Richard Fan Lectureship Award. Dr. Lam kicked off by touching on the basics of idiopathic macular holes before moving on to refractory macular holes. Significantly, Dr. Lam said that macular hole was once thought of as untreatable, being the result of tissue loss. Later, it was learned that releasing the traction will allow re- pair of macular holes. "With simple vitrectomy, some gas, you will get substantial improvement," he said. Other developments were in terms of diagnostics, with OCT ad- vancing from generation to genera- tion; to date, OCT allows surgeons to further delineate structures of the retina, allowing prognostication. Indications for surgery have also evolved, with surgery not currently indicated for stage 1 cases. However, while surgery is indicated for any stage beyond stage 1, Dr. Lam said that it is most beneficial to intervene at stage 2. "So macular hole is no longer an untreatable disease, and we want to treat as early as possible," he said. In terms of treatment, the "benchmark," he said, is to perform internal limiting membrane peeling, the rationale being to remove the scaffold for proliferation of cellular components, guaranteeing no resid- ual preexisting epiretinal membrane (ERM) and no residual vitreous cortex over the macular region. A stain is helpful; unfortunately, current stains such as indocyanine diseases. Together, NCD and aging mean multiple co-morbidities. Taking the U.S. as an example again, 21% of Medicare beneficiaries (over 65 years old) had five or more conditions but accounted for 58% of Medicare expenditures. The fragmented care and specialist-led model is a significant factor. Meanwhile, the perspective is increasingly that acute hospital-cen- tered, specialist-led models may not lead to better overall clinical outcomes while they do increase complexity and discontinuities in care and add costs. Moreover, healthcare as it is designed and delivered today is very labor intensive. In the U.S., health- care employees represented 11.8% of the total employed labor force in 2010; and yet, unlike virtually all other sectors of the U.S. economy, healthcare has experienced no gains in labor productivity over the past 20 years. As the demand for healthcare manpower increases with current models, Dr. Tan asked, where will they come from? Dr. Tan argued for a more fundamental, systems-based and system-wide change. Interventions need to target specific issues address- ing the needs of populations—for instance, programs promoting healthy lifestyles to reduce obesity and diabetes, public health inter- ventions to better control diabetes and hypertension—while utilizing and developing available tools for change—data and data analytics, technology for healthcare and health empowerment, and various financing models, and greater un- derstanding in behavioral sciences. The critical challenges, said Dr. Tan, are scaling the changes suffi- ciently to "move the needle at the systems level" and doing so while achieving outcomes that are as good or better at lower costs and with more efficient utilization of health continued on page 174 View videos from APAO 2017: EWrePlay.org Jodhbir Mehta, MD, Singapore, discusses the incidence of enhancements after SMILE and techniques to approach SMILE enhancement.

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