Q&A: Boris Stanzel on the use of methotrexate in PVR cases

Professor Boris Stanzel, MD, presented research on methotrexate's use in PVR retinal detachment surgery at the 2025 EURETINA congress, which was held in Paris, France. The study of 20 patients demonstrated significant improvements in retinal treatment, with only 1 re-detachment among 22 eyes. The research highlights methotrexate's potential as a game-changing adjunct to surgical intervention, showing promising visual acuity improvements and stable retinectomy edges, potentially revolutionizing treatment approaches for complex retinal conditions.

Note: The following conversation has been lightly edited for clarity.

Ophthalmology Times: Can you share some of the highlights from your presentation here at EURETINA?

Boris Stanzel, MD: My world, at the moment, is rocked by methotrexate used intravitrally as an adjunct to PVR retinal detachment surgery. We are presenting here at EURETINA, what we think is the first large European series. We have right now, 20 patients in our readout, which have at least a 2 months follow-up with up to 3 years follow-up. Basically, patients who've had multiple surgeries for PVR retinal detachment are then treated with methotrexate, intravitreally over the course of somewhere between 2 to 4 months, with an average of about 8.3 injections. It turns out that only 1 patient in this cohort of 22 eyes had a re-detachment, which then has been recognized at the point of full removal and therefore also taken care of.

OT: What does this research mean for providers in Europe?

Stanzel: For us, at least here in Europe, this is a absolute game changer for us, it's like anti-VEGF 20 years ago for vitreoretinal surgery. So you can't treat PvR just surgically, but methotrexate is really an adjunct that makes a difference. Notably, what has not been talked about in the US series is that most patients, when they get out of their methotrexate treatment, they remain to have an active macular edema, which responds very well to steroids. While this has been done in the US for for a bit longer time. I mean, we here in Europe haven't had experience with that, and for us, it's really that we're seeing cases that have had, say, 4 or 5 vitrectomies for PVR and the PVR keeps going.

Essentially, in terms of biomarkers, we can see that there's no more growth of PVR from the laser edges. You can do large retinectomies over 270 degrees, and you have stable retinectomy edges, no re-detachment. The surprising part is also that, like I said, the macular edema part is something that has not been talked about.

OT: How do these European results compare to results from previous studies?

Stanzel: The other thing is that the US series have only presented modest improvements in vision. We have a improvement of 4 lines. Basically, our patients start out with a logMar of about 1.0 and end up with an with 0.6 logMar, which is for us, quite encouraging. There has been some debate that methotrexate is toxic to the retina. We don't see that. It's toxic to the to the cornea, that we know and that, but that is treatable and it's transient.

OT: Can you speak to the work you've been doing with lens research?

Stanzel: We have been working with the EyeMax mono lens. This is an hyper-aspheric lens that is interesting or beneficial for patients who have a macula atrophy. So mainly in the context of a smaller geographic atrophy, we've implanted this lens. We have representing on Saturday, a series of 21 eyes. This is essentially a follow-up study report from the from last year, and to a large extent, we have maintained the data that we have seen, and there is a is a significant benefit in patients who have an extra foveal fixation, whereas the fixation area seems to predict also the response in these patients in terms of visual improvement.

Geographic atrophy is a very, functionally, very difficult disease to characterize and and typical cataract surgeons will go by visual acuity. This is not a good biomarker to go by. We have seen improvements both in patients who had foveal fixation and loss foveal fixation, although the loss fixation cases didn't matter. So we use microperimetry rather than visual acuity to guide our decisions. Patients who have a large BCVA area, that is fixation losses, those are better candidates for this lens in the typical geographic area size that we look for is a is at least 5 square millimeters, but probably not beyond 10 square millimeters.

One thing that is new this year is that we have now included an anatomic analysis in conjunction of the microperimetry, where we used OCT based artificial intelligence assessment, where we used the GA monitor from RetInSight, and interestingly, despite the fact that there was a deterioration on microperimetry, in some cases, in BCA areas, there were no losses in visual acuity, despite changes also in the indices, with the with the anatomic data. I think that's quite interesting. I would say one should see that with a caveat, because that the follow-up time is somewhere between 8 to 12 months. This is, it is a small series. This is not controlled with regular IUL, but nevertheless, this is an interesting data set that the functional data does not correlate with anatomy.