Michelle Dalton

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Migraine affects 12% of the population, and is the third most prevalent illness in the world.

It has been associated with stroke and myocardial infarction, as well as retinal vessel occlusion, ischemic optic neuropathy and normal tension glaucoma, according to Alexander Barash, MD, New York Medical Care.

Dr. Barash pointed out that these associations are stronger for those patients who have migraine with aura than without aura. Whether or not migraine can significantly increase the risk of developing primary open-angle glaucoma remains controversial.

Aura (which includes visual disturbances and/or other neurologic symptoms) occurs in about 25% of patients who experience migraine,

 and is often a cause for referral to an ophthalmologist.

“During aura, there are changes in the cerebral blood flow,” he said, noting that people who have migraine also have brains that are more easily damaged, and they need a higher blood flow to survive focal ischemia.

The pattern of migraine aura cannot be fully explained by changes in cerebral blood flow, and the areas of decreased blood flow do not directly correspond to the cortical areas responsible for the aura. “Aura may indicate more severe ischemia that predisposes to complications,” Dr. Barash said.

Using optical coherence tomography angiography (OCT-A), Dr. Barash and colleagues aimed to identify changes to macular and peripapillary retinal perfusion during migraine with aura. “We wanted to know what happens to retinal perfusion during migraine,” he said.

Dr. Barash recruited three male patients who had migraine with aura.

Patients underwent 3x3 mm and 6x6 mm macular and 4.5x4.5 mm optic nerve head OCT-A scans in both eyes during a baseline day without migraine, and during five episodes of aura and immediate post-aural migraine. The analysis included angiographic densities of macular superficial and deep capillary layers, and the radial peripapillary capillary layer. (Patients with migraine without aura were not included.)

Overall macular perfusion density was significantly decreased during post-aural migraine as compared to that of baseline in the superficial and deep macula 6x6 mm scans (p=4.2 x10^-8 and p=0.03206, respectively), and the deep macula on 3x3 mm (p=0.01996).

The overall perfusion density was significantly decreased during post-aural migraine as compared to that of aura in both the superficial and deep macula on 6x6 mm scans (p=0.00131 and p=0.00689, respectively; see figure).

There were no statistically significant changes to macular perfusion noted between baseline and aura, nor were there significant changes to the peripapillary perfusion between baseline, aura or post-aural migraine.

OCT-A detected microcirculatory disturbances during acute post-aural migraine attacks “may be an important took in elucidating the pathophysiological relationship between migraine, aura, and ischemia,” Dr. Barash said.

“There were acute reductions in retinal perfusion in real time, and this may explain the retinal thinning and progression of glaucoma that you see in patients with migraine,” he said.

Dr. Barash recommended further studies with a greater number of enrolled patients to corroborate his findings.

Dr. Barash noted that while he did not account for potential medication use, “it would be interesting to see what the results might be if patients are on vasodilators.”

Dr. Barash also acknowledged that future studies should include females, as migraine tends to affect more women than men (with a lifetime prevalence of 43% for women-about 28 million women in the U.S. alone-and only 18% for men).

The small number of patients in this study did not allow for statistical comparison of concordance between the eyes, but Dr. Barash hopes larger studies will allow for proper powering.

Panelists J. Fernando Arevalo, MD, PhD, FACS, Johns Hopkins University; and Michael S. Ip, MD, Doheny Eye Institute, said they don’t often see patients with migraine. However, while the data is interesting, neither said it would alter their current treatments for patients with retinal vein occlusion or glaucoma. 


	P: 212/243-2300
	This article is derived from Dr. Barash’s presentation at the 2019 American Society of Retina Specialists annual meeting in Chicago. He has no financial disclosures.

1. Migraine Research Foundation. About Migraine. Available at: https://migraineresearchfoundation.org/about-migraine/ migraine-facts/
	2. Xu C, Li J, Li Z, Mao X. Migraine as a risk factor for primary open angle glaucoma. Medicine (Baltimore). doi: 10.1097/ MD.0000000000011377

Articles

OCT-A detected microcirculatory disturbances during acute post-aural migraine attacks may be an important tool in elucidating the pathophysiological relationship between migraine, aura, and ischemia.

Migraines, retinal perfusion: Pain for physicians, patients

While articles and discussions on minimally invasive glaucoma surgery (MIGS) seem to be everywhere (for better or worse), “trabeculectomy will survive,” said Kuldev Singh, MD, because of the aging population, the ease of postoperative titration, and the need for even lower pressures.

The glaucoma device market is expected to grow at three to four times the rate of the refractive and cataract surgery and the IOL markets over the next few years, Dr. Singh said.

Dr. Singh’s presentation was part of the 23rd Annual Glaucoma Symposium at the 2019 Glaucoma 360 meeting. Dr. Singh is professor of ophthalmology and director of the Glaucoma Service, Stanford University School of Medicine, Palo Alto, CA. “We currently have 17 distinct procedures for glaucoma inflow/outflow procedures,” Dr. Singh pointed out. “We have non-device MIGS procedures, and we have lasers that reduce aqueous production.”

All of these procedures are leading to a “Glaucoma Restoration” period, likening the current state of glaucoma to a “Glaucoma Renaissance.”

“Not all these procedures and devices will survive,” he said. “There will always be a role for trabeculectomy as a result.”

In the new era, there may even be a greater need for trabeculectomy than there is now, Dr. Singh said. Among his predictions:

The entire MIGS segment will continue to grow. The procedures “have really revolutionized how we care for patients with mild-to-moderate disease,” Dr. Singh said. “We offer a non-pharmaceutical option for these patients and that category will continue to grow.”

Trabeculectomy will continue to be relevant, especially when MIGS fail, or when patients have more severe disease or are older and need lower pressures. “From a numbers standpoint, there are going to be more people who need tra-beculectomy 10 or 15 years from now than there ever have been,” he added.

But will there be people out there who know how to perform the surgery? “That’s a different issue,” Dr. Singh said.

The “ideal” intraocular pressure (IOP) level is continually decreasing-from 21 mm Hg, to 18 mm Hg, then to 12 mm Hg.

“Most people don’t need 12 mm Hg,” Dr. Singh said. “But there’s a small subset in whom 12 mm Hg is not enough-they need 6 mm Hg. Six will be the new 12.”

He added that procedures, such as MIGS, won’t be able to achieve those lower levels for people with much worse disease.

There will always be two types of glaucoma patients, Dr. Singh said-those who continually do well regardless of treatment, and those who continually fare poorly, regardless of treatment.

“We have to know our patients,” Dr. Singh outlined. “The treatment can't be worse than disease. And fortunately, there are many more with mild disease and low risk for progression than high risk for progression.”

MIGS and drops will continue to be the norm for “Glaucoma Lite,” Dr. Singh said. 

But for that subset of patients who progress fast and have catastrophic outcomes, treatment needs to be aggressive. The aging population means it is likely glaucoma specialists are going to be seeing greater numbers of patients who fall into that category.

“As patients age, they start to lose optic nerve tissue from the aging process,” Dr. Singh said. “Glaucoma becomes difficult to treat in patients with IOPs of 10 mm Hg to 15 mm Hg in their 80s and 90s who may be going downhill very fast.”

Be aggressive in aiming for lower pressures, he advised, adding that only trabeculectomy achieves that. Dr. Singh recommends using lower dose mitomycin over a broader area, resulting in more diffuse, minimally vascular blebs.

Dr. Singh’s preferred trabeculectomy technique includes making a limbus-based flap in the majority of his patients (about 85%), but notes in Asian patients, he may prefer fornix-based procedure. A limbus-based procedure allows surgeons “to cut sutures early in the postoperative period without worrying about leaks,” he added.

While Dr. Singh acknowledges trabeculectomies are more work than other procedures, having an assistant to hold the conjunctiva or providing more exposure “makes limbus-based trabeculectomy a lot easier.”

Trabeculectomies done properly “require a lot of postoperative work, a lot of care.” Dr. Singh believes releasable suture lysis is as important as antifibrotics, because that will allow surgeons “to titrate pressure postoperatively,” he explained. “Those two together have made trabeculectomy a unique procedure.

“We can perform the surgery and postoperatively aim for whatever IOP you think is best, based on how you release sutures,” he added. “None of the newer procedures offers that. That’s one of the real advantages of this type of approach.”

Dr. Singh also advised that when performing the newer procedures, “Don't ruin the superior conjunctiva. Most likely, these patients are going to need a trabeculectomy if they have bad disease,” he said.

“I like procedures in the canal and in the eye that don’t adversely impact the conjunctiva,” he said. “I have had patients who underwent some of these newer procedures and now have to go straight to a tube because there is not enough healthy conjunctiva at 12 o’clock to perform a trabeculectomy.”

Finally, Dr. Singh aims to see wound closure at the time of surgery and will inflate the bleb.

“Most of these patients will have double-digit IOPs in the early postoperative period,” he said. “I don't like to see early hypotony-you want to quiet the eye down and remove stitches one to two weeks out rather than right away. The eye will do much better.”

MIGS and Trab: Peaceful co-existence

2019 American Society of Retinal Specialists

 (ASRS) annual meeting is dedicating an entire session to honoring current and future leaders in the retina community.

The event will be held July 26-30 at the Hyatt Regency Chicago, offering a forum on the latest developments in retina.

 will recognize leaders whose dedication and outstanding contributions have helped evolve the field and improve patient care.

Carl C. Awh, MD, and John S. Pollack, MD, will serve as moderators for the session. Several awards will be given out. These include:


	The Retina Research Foundation (RRF) will present its Gertrude D. Pyron Award to Joan M. O’Brien, MD, chairperson of the department of Ophthalmology, director of the Scheie Eye Institute, and William F. Norris and George E. de Schweinitz Professor of Ophthalmology at the University of Pennsylvania School of Medicine. She will speak on “Genetics of Retinal Disease.”

In addition to her duties as a chairman and ocular oncologist, Dr. O’Brien serves as the principal investigator of a five-year, $11.25 million R01 glaucoma genetics study on African Americans that has enrolled more than 10,000 patients in Philadelphia and has the potential to provide more targeted screenings and treatments for this disease.

Dr. O’Brien’s research on ocular genetics has advanced diagnostic and treatment options for several diseases. Working with Boris Bastian’s lab at the University of California-San Francisco (UCSF), Dr. O’Brien discovered and characterized two novel oncogenes in uveal melanoma, GNAQ and GNA11, which were published in Nature and the New England Journal of Medicine. This discovery allowed for personalized, targeted therapy for patients with uveal melanoma, improving their quality of life.

Dr. O’Brien also identified numerous unique pathogenic variants in the retinoblastoma gene (RB1). This testing, which allowed retinoblastoma therapy to be directed according to underlying genetic risk, is now offered nationwide at no charge through the National Eye Institute’s (NEI’s) eyeGENE initiative.

The Pyron Award is endowed by an estate gift from Gertrude D. Pyron, an imminent geologist during her lifetime, who bequest to the Retina Research Foundation (RRF) out of admiration for Alice McPherson, MD’s leadership in vision science. The RRF was founded by Dr. McPherson, an ASRS member, in 1969 to establish and fund programs for the eradication of vitreoretinal disease.

Dr. O’Brien will receive a $30,000 cash prize, including a $5,000 personal honorarium and a $25,000 research grant.


	The ASRS Founders Award recognizes individuals who have made major contributions to the advancement of vitreoretinal surgery, treatment, research, surgical instrumentation, and patient care.

This year’s recipient, Lawrence A. Yannuzzi, MD, will speak on “The Legend of Cuticular Drusen.”

Dr. Yannuzzi is a professor of clinical ophthalmology at Columbia University (New York), and has authored nine books and more than 270 publications. He has received a lifetime achievement award from the American Academy of Ophthalmology, and is the founder of the Vitreoretinal Fellowship, head and founder of the LuEsther T. Mertz Retinal Research Center and founder of The Macula Foundation.

The Founders Award was first presented in 1997 to honor the efforts of the society’s founders, Drs. Jerald A. Bovino, Roy A. Levit, and Allen Z. Verne, for their foresight, dedication, and leadership in establishing the society as an open, democratic, worldwide organization dedicated to the advancement of vitreoretinal surgery and the study of vitreoretinal diseases.


	
	The Crystal Apple is a special recognition that is presented to an ASRS member who has gone to great lengths to advance the education and professional development of young vitreoretinal specialists.

In addition to receiving the award, each year's recipient also presents a distinguished lecture during the Early Career Section's Annual Meeting luncheon.
	This year’s recipient is Seenu M. Hariprasad, MD. He is the inaugural Shui-Chin Lee Professor of Ophthalmology and visual science chief, Vitreoretinal Service at the University of Chicago.

The ASRS Service Award is being presented to Kirk H. Packo, MD, FACS, vitreoretinal surgeon, educator, researcher and inventor of more than 25 surgical instruments who also holds two U.S. patents. He is professor and chairman of the Department of Ophthalmology at Rush University Medical Center in Chicago, where he also serves as Director of the Retina Section and co-founder of the medical center’s Fellowship in Vitreoretinal Surgery.

“Doing something ‘good enough’ has never been acceptable,” Dr. Packo said. “I approach my patients in the same way. If the patient were me or someone in my family, I would want the surgery to done absolutely right. I have never accepted less.”

The Retina Young Investigator Award is given in recognition of an outstanding paper published during the past year and other accomplishments of a young investigator (45 years of age or younger) who shows potential for impactful contributions to the field in the future.

This year’s recipient, Sophie J. Bakri, MD, is being recognized for her paper “Question Everything and Challenge the Dogma.”
	 

Annual meeting schedule to include presentations, live surgery, awards

ASRS sets sights on Windy City for conference

2019 American Society of Retina Specialists Annual Meeting

 offers balanced lectures, symposia, and courses with an ample amount of social events.

Beyond the welcome receptions and fundraisers to networking lunches and dinners, the event also is offering expanded educational opportunities.


	
	ASRS is debuting an ambitious live surgery symposium on Tuesday, July 30. Attendees will watch three hours of live vitreoretinal surgery beamed into the auditorium from three surgery sites in the United States, Europe and the Middle East.

The session will be moderated by Kourous Rezaei, MD, and a panel of expert surgeons in Chicago. A surgeon moderator in each operating room will offer their expertise as the surgeries unfold.

In response to requests for more discussion on presented papers, 

 has shortened the presentation time to allow for more moderated question-and-answer sessions after every four to six talks.

ASRS will now conclude each major area with a take-home panel discussion in which experts will “discuss topics of current clinical relevance to provide information you can put to immediate use in the office or in the OR.”

The LAST WORD will be the final session of the meeting, where selected authors, determined during the meeting, will be invited to present a two-minute summary of their work, followed by audience and expert panel discussion. 

“Sometimes a topic deserves more time… the most controversial, the most fascinating, the most important, the most memorable presentations,” said ASRS Program Chairman Carl C. Awh, MD.

OCT and OCTA: Seeing deeper into sickle cell retinopathy 


	The annual meeting kicks off Friday with instructional courses in the afternoon.

All registered attendees and guests are invited to the Welcome Reception, being held this year at 

, where ASRS will take over the entire 60,000 square foot area for an evening of food and drink.

The Women in Retina group will host a luncheon (complete with keynote speaker) and a dinner meeting to hear about unique retina cases.

The Fellow-in-Training Section reception is scheduled for Saturday, and is open to all members.

At 6 a.m. Sunday, the Foundation of the ASRS will host its 

 in Lincoln Park. Outlook Therapeutics has supported this charity event this year.

Registration continues until Saturday, with a $50 donation. For more information, contact Chayal Patel.


	The Early Career Section is hosting its annual luncheon symposium on Sunday. It will feature the 2019 Crystal Apple Award winner Seenu Hariprasad, MD.

For those on the other side of the employment spectrum, John T. Thompson, MD, will moderate an expert panel discussion on strategies to prepare for retirement. Speakers include Jerry Bovino, MD, Brian Conway, MD, Richard Garfinkel, MD, Alan Verne, MD, and David Williams, MD.

Attendees should be prepared with questions for an interactive audience question/comment period.

The annual black tie gala dinner will be held Sunday night at the Field Museum of Natural History.

The International Members and Delegates Breakfast is scheduled for Monday morning.

Festivities will culminate on Monday evening, when ASRS invites all attendees to its foundation fundraiser, a  Chicago architecture tour and river cruise.

Rated by TripAdvisor as the “top tour in Chicago and one of the top 10 tours in the U.S.,” the 90-minute tour on the Chicago River will be filled with Chicago’s 100-year coming-of-age story, as told through its architecture.

Proceeds from the event will help the foundation provide enhanced patient education materials on SavingVision.org.

Tickets are $60 per person and will include one drink ticket.
	 

Beyond the sessions, this year’s conference offers multiple events for attendees.

Author | Michelle Dalton

Articles

Migraines, retinal perfusion: Pain for physicians, patients

MIGS and Trab: Peaceful co-existence

ASRS sets sights on Windy City for conference

ASRS 2019 offers expanded education, social opportunities