PROPELLED BY PROGRESS

Francesco Bandello MD, FEBO, is the president-elect of EURETINA. He first became involved with the organisation when his mentor Rosario Brancato MD was working with Gisbert Richard MD to get the EURETINA meetings project started. Dr Bandello was among the very small group of doctors in attendance at the first meeting in Hamburg in 2001. He has since played an active role in every subsequent meeting and has watched as EURETINA became the bestattended retina meeting in the world. In a Newsmaker interview, he spoke with EuroTimes contributing editor Roibeard O’hEineachain, about the advances in diagnosis and treatment that have brought retinal specialists into the spotlight in recent years.

An important factor in EURETINA’s success has been the wise and very fortunate choices made by the people who were managing the society. Mainly thanks to Gisbert Richard’s intuitions, the result has been a series of good, wellorganised meetings, in beautiful places, with interesting scientific programmes, and with interesting speakers. All of these factors were to help make EURETINA the most important retinal society in the world, which I believe it to be today.

But the achievement of two important milestones was another of the main reasons behind EURETINA’s success. The first milestone was the success achieved in diagnosing retinal diseases by OCT, which produces very reliable and quantifiable results and is completely non-invasive. The other milestone, some time after the introduction of OCT, was the advent of intravitreal therapies with steroids and anti- VEGF agents for treating retinal diseases. Together these two milestones have totally changed our patients’ prognosis, and this has greatly increased the interest with which ophthalmologists now look at retinal disease. It also means there is now a much greater market for retinal specialists.

There can sometimes be a rivalry within the retinal specialty between those taking a medical approach and those taking a surgical approach to the treatment of retinal disease. The medical approaches are typically aimed at intervening in some way in the underlying pathological mechanisms and generally involve repeated administration of therapeutic agents. The surgical approach on the other hand aims to repair the damage to the eye in a much more direct and immediate fashion.

The recent introduction of enzymatic vitreolysis as a treatment for vitreomacular traction may require some gymnastics on the part of both subspecialties if they are to work together in harmony, because vitreolysis is a medical treatment which achieves a result that was previously possible only through surgical vitrectomy. We need to encourage medical retinal specialists to work together because we will need the competence and expertise of both subspecialties. This may be less of a concern in countries that have health systems which do not separate the two subspecialties.

Meanwhile, the indications for anti- VEGF continue to expand and now include diabetic macular oedema, and also prophylaxis against intraoperative bleeding in eyes undergoing surgery for proliferative diabetic retinopathy. However, there is a danger that anti-VEGF agents will be overused and used inappropriately. We have already seen that happen with photodynamic therapy, where some who were not retinal specialists started to do PDT treatments, sometimes very inappropriately, for example, in patients with dry AMD and Stargardt’s disease. This also happened with anti-VEGF and it is still happening.

Our treatments for retinal disease should be evidence-based and the quality of the evidence will have a bearing on the quality of the treatment. Frequently it is the case when drug companies sponsor large multicentre studies that the indication for the treatment under investigation is defined rather broadly and little attention is initially paid to important subgroups within the patient population that may have a better or worse response to the agent under investigation.

For that reason, EURETINA is in the process of developing a standard protocol for conducting trials and reporting results. The aim is that studies conducted according to the guidelines will produce results that are more clinically useful. It may not be easy to engage drug companies in this process since their motives are much more profit-oriented. On the other hand, the Novartis-sponsored Luminous prospective study provides a great example of how physicians and industry can work together on a broad scale for the benefit of patients.

There remain many important milestones that we have yet to reach. For example, we need to develop diagnostic techniques that will detect more accurately and consistently the structural changes that correspond with losses and gains in vision. In addition, we need to develop intravitreal agents that will remain effective in the eye for longer than is currently the case.

In the not-too-distant future we will most likely see the introduction of intravitreal implants which remain effective for several years. That may well spell the end of the current golden age for retinal specialists since our expertise may be in much less demand. In the meantime, it is among EURETINA’s tasks to convince those in charge of health systems across Europe of the genuine benefit that patients with retinal disease can gain from the vision that modern treatments can restore and preserve.