3D interventions, a new frontier for retinal surgery

Gene therapy, stem cells and technological innovation are the weapons available to ophthalmological experts against eye diseases. This is what emerged at the last Congress of the Italian Society of the Retina. “Thanks to new three-dimensional screens that use a digitization of the eye image, retinal surgery has finally become hi-tech. With 3D images it is now easier to perform perfect vitrectomies, to do things that were previously very difficult with a margin of error now reduced. This three-dimensional system will lead us to be able to do without the microscope in the operating room by replacing it with cameras. Everything can then be recorded, reviewed, analyzed. Not only that, this method allows us to be able to carry out targeted injection therapies and customized because the technology is much more precise than a few years ago “. Thus Cesare Mariotti, president of the Italian Society of the retina, in his speech at the Sir National Congress which took place in Venice from 1 to 2 July. Objective of the two days: to take stock of screening, risk factors, differential diagnoses, surgical techniques and new drugs for diseases affecting the retina, in particular diabetic retinopathy and macular degeneration due to aging. “As for the surgery of age-related macular degeneration – says Mariotti, also director of the Oculistic Clinic of the Polytechnic University of Marche, Aou Ospedali Riuniti of Ancona – to date we have multiple therapies already tested and certainly a promising endovitrial gene therapy, which uses an adeno-associated virus (Aav) as a vehicle to transfer genes to specific cells. It is a treatment that represents a great improvement in the quality of life for those suffering from this disease, that is 50% of the population over 65. Just as surgery for large hemorrhages is fundamental. Macular degeneration produces a large subretinal hemorrhage. Thanks to the new methods we can dissolve the hemorrhage with a particular substance and continue our therapy with injections, or cut the retina to eliminate the large blood clot Cell transplant is very important and stem cells as is autologous choroid transplantation. The latter is a complex intervention that consists in the transplantation of a choroid flap taken from the periphery of the same eye and positioned in the center of the retina, in order to restore the metabolic supply to the macula “. There are two types of macular degeneration, ‘ dry ‘and’ wet ‘, both linked to aging of the eye. The wet one is characterized above all by the abnormal formation of new blood vessels that damage the cells of the retina. “The good news for patients with wet macular degeneration – holds to specify the president of Sir – is that we can count on a class of inhibitors of Vegf (Vascular endothelial growth factor) that inhibit the formation of abnormal blood vessels and prevent vision loss, with a good percentage of success. As for dry macular degeneration, there are drugs still under study, but we are still working on this front. One thing is certain: there are few patients with age-related macular degeneration forced to undergo surgery, less than 10%, because fortunately we are able to treat them with drug therapies. “For patients with diabetic retinopathy, on the other hand, the room surgery represents a greater possibility. “In 30% of cases these patients, especially men, must be operated on – explains Mariotti, one of the first in Italy to use cutting-edge techniques in retinal surgery – because removing the vitreous from a diabetic patient greatly reduces the risk of vitro-retinal diseases. But the reverse is also true. Once the vitreous is removed, if we use the drugs used for the treatment of macular degeneration, we would notice that the activity time of these therapies is reduced. Unfortunately, they are less effective precisely because the vitreous is no longer there. So all options have to be evaluated. Surely everything should be done to prevent the diabetic patient from arriving in the operating room. Thanks to the improvement of pre-operative exams, to the integrated system between 3D interventions, image digitization and intraoperative Oct, we are able to understand when we can perform a routine intervention, such as that to remove diabetic macular edema, the accumulation of liquids. in the macula, the central part of the retina, and when instead we have to deal with the detachment of the retina, since the patients in the meantime have not treated themselves adequately “. Mariotti has no doubts about the use of stem cells:” Their transplant today is very requested, fortunately we have the means to do so. But it is – he warns – a particular surgery, through which stem cells are introduced under the retina with specific needles, so only those who already have a long experience in vitroretinal surgery can perform it. “Surgery, however, must be understood as extreme. ratio, is the thought of Mariotti: “It must intervene when the pathologies become complicated with the hemorrhagic components. The right policy – he concludes – is to find centers where the patient can find all the information, right from the beginning of his / her diagnostic-therapeutic path. Our goal, in fact, is to see fewer and fewer patients with diabetic retinopathy in the operating room. For this reason it is essential that the diabetologist refer the patient immediately to the ophthalmologist “.

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