25th RCOphth Congress, President's Session paper: 25 years of progress in medical retina

Abstract

The quarter century since the foundation of the Royal College of Ophthalmologists has coincided with immense change in the subspecialty of medical retina, which has moved from being the province of a few dedicated enthusiasts to being an integral, core part of ophthalmology in every eye department. In age-related macular degeneration, there has been a move away from targeted, destructive laser therapy, dependent on fluorescein angiography to intravitreal injection therapy of anti-growth factor agents, largely guided by optical coherence tomography. As a result of these changes, ophthalmologists have witnessed a marked improvement in visual outcomes for their patients with wet age-related macular degeneration (AMD), while at the same time developing and enacting entirely novel ways of delivering care. In the field of diabetic retinopathy, this period also saw advances in laser technology and a move away from highly destructive laser photocoagulation treatment to gentler retinal laser treatments. The introduction of intravitreal therapies, both steroids and anti-growth factor agents, has further advanced the treatment of diabetic macular oedema. This era has also seen in the United Kingdom the introduction of a coordinated national diabetic retinopathy screening programme, which offers an increasing hope that the burden of blindness from diabetic eye disease can be lessened. Exciting future advances in retinal imaging, genetics, and pharmacology will allow us to further improve outcomes for our patients and for ophthalmologists specialising in medical retina, the future looks very exciting but increasingly busy.

Figure 1

Small extrafoveal CNV treated with argon green laser photocoagulation in 1989. (a) FFA pre-laser. (b) Red-free photograph immediately post-laser showing overlapping, confluent burns. (c) Fluorescein angiography 1-week post-laser treatment. (d) Late phase fluorescein angiography in 1999 showing laser creep and scar extension toward fovea.

Figure 2

Fundus photograph and OCT image of diabetic patient with threshold laser photocoagulation burns, showing how OCT can facilitate subthreshold and threshold laser treatment.

Figure 3

Map of constituent parts of the Birmingham and Black Country Diabetic Retinopathy Screening Service. By 2010, when this schematic map was created, there were 125 000 annual screens being performed, at 106 screening sites, referring into 7 hospital ophthalmology departments.

Figure 4

Photograph of case notes of patient in pre-digital era of 1992, showing Polaroid prints and fluorescein angiography prints performed to guide laser treatment.

Figure 5

Post-laser treatment notes and photographs of same case as in Figure 2, showing successful laser treatment of large classic, extrafoveal CNV. The patient went on to retain good vision for 20 years.