EDITORIAL - RETINAL CHALLENGE

Ophthalmologists treating retinal disease today have more resources at their disposal than ever before. Imaging techniques have become fast, patient-friendly and refined, as ever more detailed information can be gleaned within the blink of an eye. High-budget research has led to the development of several highly effective new drugs, as well as lasers that are subtler and less destructive. 

Angio-optical coherence tomography (angio-OCT) is generating the same type of interest and enthusiasm that greeted the introduction of fluorescein angiography and OCT. Next-generation anti-VEGF molecules promise to either extend the time between serial intravitreal injections, or at least supplement our arsenal in refractory cases. Sustained-release intravitreal steroid depots allow us to tackle stubborn macular oedema due to a range of different etiologies. 

For the retinal surgeon, advances beyond thinner-gauge instrumentation have expanded the indications for surgery and have improved both recovery times and final results. LED light sources provide bright endo-illumination for more complete vitreous removal. Powerful dyes allow more accurate epiretinal membrane peeling. And ultra-high vitretomy cut rates reduce intraoperative vitreoretinal traction to nearly negligible levels, streamlining surgery.

Healthcare systems across the world have taken notice of the benefits of aggressive treatment of retinal disease. Sums that were previously reserved for life-threatening diseases are now being spent on keeping foveas fluid-free. Many insurers are willing to spend thousands of euros to make sure that patients maintain their sight. This is due, in part, to the realisation that visually independent people are less likely to suffer other, potentially more expensive ailments. 

INTERNATIONAL CAMPAIGN

But it is also the result of an effective international campaign, advanced by leaders of both research and industry, to keep policymakers focussed on the importance of sight. On the other hand, our work has not necessarily gotten easier.
We are perpetually aware of the potential benefits of treatment given the right combination of the modalities at our disposal, so we are not easily satisfied. Neither are our patients, who are now less likely to accept the termination of treatment. They are often very well-informed and would like to remain highly active into old age, despite suffering from retinal disease that until 10 years ago was incapacitating. And because high-definition imaging makes it impossible to ignore even the tiniest abnormalities, we strive for perfection. 
Significant challenges remain. Visual recovery rates after successful reattachment of macula-involving retinal detachments have barely improved in the past century. Long-standing macular oedema is still often a death sentence for central visual acuity. There is still no effective prophylaxis for proliferative vitreoretinopathy, nor is its treatment atraumatic for the retina. Retinal ischaemia remains a serious challenge, and macular atrophy still threatens the success of well-controlled neovascular age-related macular degeneration (AMD). As for retinal vascular occlusions, they can leave both doctor and patient searching hopelessly for solutions. 
What is most encouraging is that every new development, whether diagnostic or therapeutic, is being studied in order to determine not only the modalities’ value, but also the optimal use. Which anti-VEGF should we use? And when? And how often? And based on which criteria? The results of large, well-organised trials seem to emerge in highly-regarded, peer-reviewed journals on a monthly basis. When should we add laser to the treatment regimen? How about steroids? And is angio-OCT worth all the hype? 
Rest assured, the best minds in our midst are tackling these questions with enthusiasm.