Early vitrectomy for severe proliferative diabetic retinopathy in eyes with useful vision. Results of a randomized trial--Diabetic Retinopathy Vitrectomy Study Report 3. The Diabetic Retinopathy Vitrectomy Study Research Group

Surgical and visual outcome following 20-gauge vitrectomy in proliferative diabetic retinopathy over a 10-year period, evidence for change in practice

INTRODUCTION

The study reports 10-year anatomical and visual outcome in patients who underwent pars plana vitrectomy (PPV) for complications due to proliferative diabetic retinopathy (PDR).

METHODS

Retrospective analysis of patients undergoing 20 G PPV from January 1999 to May 2010 for tractional retinal detachment (TRD) and non-clearing vitreous hemorrhage (NCVH) secondary to PDR recorded prospectively on an electronic patient record. The primary aim was to study anatomical success and eyes with visual acuity (VA) of ≤ 0.3 logMAR at last follow-up.

RESULTS

There were 346 eyes of 249 patients with mean age of 55.63 years and follow-up of 1.44 years. In all, 95.3% of eyes had a flat retina at final follow-up. Overall 136/346 (39.4%) eyes had final VA of logMAR ≤ 0.3 (Snellen 6/12) and 129 (37.3%) had logMAR ≥ 1.0 (Snellen 6/60). In all, 50/181 (27.6%) eyes with TRD and 84/165 (50.9%) with NCVH achieved final VA of ≤ 0.3 logMAR (Snellen 6/12). A total of 218 (63.1%) showed ≥ 0.3 logMAR improvement from baseline to last follow-up. Both preoperative VA and final postoperative (post-op) VA (P<0.001) improved significantly with each year from 1999 to 2010. The commonest peroperative complication was iatrogenic retinal tear formation (28.4%). This was a risk factor for the development of post-op retinal detachment, odds ratio: 3.90 (95% confidence interval: 1.91-7.97, P = 0.0002). Silicone oil was used in 5.2% of patients at the primary procedure. In all, 9.2% required removal of non clearing post vitrectomy hemorrhage.

CONCLUSIONS

Outcomes from vitreoretinal surgery for complications of diabetic retinopathy have improved. In addition, the visual outcome after diabetic vitrectomy steadily improved over the 10-year period, which may in part be due to the move to operate on patients with better vision.

Visual and anatomical outcomes following vitrectomy for complications of diabetic retinopathy: the DRIVE UK study

INTRODUCTION

End-stage diabetic eye disease is an important cause of severe visual impairment in the working-age group. With the increasing availability of refined surgical techniques as well as the early diagnosis of disease because of screening, one would predict that the prevalence of this condition is decreasing and the visual outcome is improving.

AIM

To study the prevalence and visual outcome following vitrectomy for complications of diabetic retinopathy.

MATERIALS AND METHODS

This study identified the patients who underwent vitrectomy from January 2007 to December 2009 because of diabetes-related complications in South East London. Data collected included baseline demographics, best-corrected visual acuity, indication for the vitrectomy, complication, outcome, and duration of follow-up.

RESULTS

The prevalence of people requiring vitrectomy who are registered in the diabetes register of this region was 2 per 1000 people with diabetes. Vitrectomy was required in 185 eyes of 158 patients during this period. These included 83 Caucasians, 51 Afro-Caribbeans, 17 South Asians, and 7 from other ethnic groups. There were 58 patients with type I diabetes and 100 with type II, with a mean duration of diabetes of 23 and 16.5 years, respectively. The reason for vitrectomy included tractional retinal detachment (TRD) in 109 eyes, non-clearing vitreous haemorrhage (NCVH) in 68 eyes, and other causes in 8 eyes. In all, 50% of the eyes with TRD and NCVH, and 87% of the eyes with NCVH improved by at least three ETDRS lines at 12 months. Poor predictors of visual success included longer duration of diabetes (OR: 0.69), use of insulin (OR: 0.04), presence of ischaemic heart disease (OR: 0.04), delay in surgery (OR: 0.59), and the failure to attend clinic appointments (OR: 0.58). Preoperative use of intravitreal bevacizumab in eyes with TRD undergoing vitrectomy showed a marginal beneficial effect on co-existent maculopathy (P=0.08) and required less laser intervention post procedure, but did not affect the number of episodes of late-onset vitreous haemorrhage post vitrectomy (P=0.81).

CONCLUSION

Visual outcome has improved significantly in eyes with complications due to diabetic retinopathy compared with the previously reported Diabetic Vitrectomy Study.

Current and future approaches in the prevention and treatment of diabetic retinopathy

Diabetic retinopathy (DR) is a major cause of blindness worldwide and is the number one cause of blindness in working-age individuals in developed countries. We review the current literature and discuss the pathogenesis, modifying risk factors, genetics, and treatment of DR. Special focus is placed on the rationale and effectiveness of therapeutic modalities, both current and future.

Diabetic retinopathy - An update

Management of diabetes should involve both systemic and ocular aspects. Control of hyperglycemia, hypertension and dyslipidemia are of major role in the management of diabetic retinopathy. In the ocular part; laser treatment remains the cornerstone of treatment of diabetic macular edema (focal/grid), severe non-proliferative and proliferative diabetic retinopathy (panretinal photocoagulation). There is a strong support to combination therapy. Using one or two intravitreal injections such as anti-VEGF and or steroid to reduce central macular thickness followed by focal or grid laser to give a sustained response may offer an alternative to treatment in diabetic macular edema. Anti-VEGF were found to be effective as an adjunct therapy in proliferative diabetic retinopathy patient who is going to have vitrectomy for vitreous hemorrhage with neovascularization, panretinal photocoagulation, and other ocular surgery such as cases with neovascular glaucoma and cataract with refractory macular edema.

Review of therapeutic advances in diabetic retinopathy

Diabetic retinopathy is a common microvascular complication of prolonged diabetes. It is one of the leading causes of vision loss in working age adults and a significant source of morbidity. To reduce the incidence and severity of diabetic retinopathy, it is important to identify patients at risk and promptly implement intensive glycemic and hypertensive control. To date, there are many interventions that can limit moderate and severe vision loss in people with diabetes, including laser photocoagulation, vitrectomy surgery, and intravitreal pharmacological injections. This review aims to define the different stages of diabetic retinopathy and the important therapeutic advances developed to address the major causes of vision loss in each stage.

Diabetic retinopathy

Diabetic retinopathy is a common and specific microvascular complication of diabetes, and remains the leading cause of preventable blindness in working-aged people. It is identified in a third of people with diabetes and associated with increased risk of life-threatening systemic vascular complications, including stroke, coronary heart disease, and heart failure. Optimum control of blood glucose, blood pressure, and possibly blood lipids remains the foundation for reduction of risk of retinopathy development and progression. Timely laser therapy is effective for preservation of sight in proliferative retinopathy and macular oedema, but its ability to reverse visual loss is poor. Vitrectomy surgery might occasionally be needed for advanced retinopathy. New therapies, such as intraocular injection of steroids and antivascular endothelial growth-factor agents, are less destructive to the retina than are older therapies, and could be useful in patients who respond poorly to conventional therapy. The outlook for future treatment modalities, such as inhibition of other angiogenic factors, regenerative therapy, and topical therapy, is promising.

Reasons for and management of postvitrectomy vitreous hemorrhage in proliferative diabetic retinopathy

OBJECTIVE

To analyze the reasons for postvitrectomy vitreous hemorrhage in proliferative diabetic retinopathy (PDR), and to evaluate the effects of retreatment.

DESIGN

Retrospective, nonrandomized, observational case series.

METHODS

Three hundred and fifteen eyes of 302 consecutive patients underwent primary standard three-port vitrectomy with 20-gauge instruments for complications of PDR from 2000 to 2006. One hundred and forty-two patients were male, and 160 were female. The age ranged from 38 to 72 years with a mean of 56 years. There were 32 eyes which developed postvitrectomy vitreous hemorrhage during follow-up. The mean follow-up was 12 months with a range from 3 to 48 months.

RESULTS

Of 315 eyes with PDR and receiving pars plana vitrectomy, 32 eyes had postvitrectomy vitreous hemorrhage. The onset of recurrent vitreous hemorrhage ranged from 1 to 210 days with an average of 51 days. The reasons for postvitrectomy vitreous hemorrhage in PDR mainly included fibrovascular ingrowth at sclerotomy sites (9 eyes), residual or recurrent neovascular membrane on the optic nerve (6 eyes), insufficient retinal photocoagulation (7 eyes), residual and recurrent epiretinal proliferative membrane (3 eyes), retinal vein occlusion (2 eyes), postoperative low intraocular pressure (2 eyes), and ocular trauma (3 eyes). The visual acuity increased in 31 eyes (96.88%), and decreased in 1 eye (3.12%) after retreatment. The postoperative complications following the treatment of recurrent vitreous hemorrhage mainly included posterior synechia of the iris (3 eyes), nucleus sclerosis (18 eyes), and delayed healing of corneal epithelium (3 eyes).

CONCLUSION

Vitrectomy is a safe and effective method for treating PDR. Appropriate and complete analysis of postvitrectomy vitreous hemorrhage can significantly improve the primary treatment effects for PDR.

Endoplasmic reticulum stress and diabetic retinopathy

Endoplasmic reticulum (ER) stress is involved in the pathogenesis of several diseases including Alzheimer disease and Parkinson disease. Many recent studies have shown that ER stress is related to the pathogenesis of diabetes mellitus, and with the death of pancreatic beta-cells, insulin resistance, and the death of the vascular cells in the retina. Diabetic retinopathy is a major complication of diabetes and results in death of both neural and vascular cells. Because the death of the neurons directly affects visual function, the precise mechanism causing the death of neurons in early diabetic retinopathy must be determined. The ideal therapy for preventing the onset and the progression of diabetic retinopathy would be to treat the factors involved with both the vascular and neuronal abnormalities in diabetic retinopathy. In this review, we present evidence that ER stress is involved in the death of both retinal neurons and vascular cells in diabetic eyes, and thus reducing or blocking ER stress may be a potential therapy for preventing the onset and the progression of diabetic retinopathy.

Endoplasmic reticulum stress and diabetic retinopathy

Endoplasmic reticulum (ER) stress is involved in the pathogenesis of several diseases including Alzheimer disease and Parkinson disease. Many recent studies have shown that ER stress is related to the pathogenesis of diabetes mellitus, and with the death of pancreatic β-cells, insulin resistance, and the death of the vascular cells in the retina. Diabetic retinopathy is a major complication of diabetes and results in death of both neural and vascular cells. Because the death of the neurons directly affects visual function, the precise mechanism causing the death of neurons in early diabetic retinopathy must be determined. The ideal therapy for preventing the onset and the progression of diabetic retinopathy would be to treat the factors involved with both the vascular and neuronal abnormalities in diabetic retinopathy. In this review, we present evidence that ER stress is involved in the death of both retinal neurons and vascular cells in diabetic eyes, and thus reducing or blocking ER stress may be a potential therapy for preventing the onset and the progression of diabetic retinopathy.

Intravitreal bevacizumab in active progressive proliferative diabetic retinopathy

BACKGROUND

Vitreous concentration of vascular endothelial growth factor (VEGF) rises significantly during proliferative diabetic retinopathy (PDR). Bevacizumab (Avastin) is a humanized monoclonal antibody to VEGF. Intravitreal administration of bevacizumab (IVB) has recently been shown to be effective in some ocular neovascularizations, including PDR. In this study we evaluate the efficacy of IVB in eyes with active, progressive PDR.

METHODS

In an interventional prospective case series, eyes with active, progressive PDR underwent one to three IVB injections (1.25 mg) at intervals of either 6 or 12 weeks. Complete ophthalmic examinations and color fundus photography were performed at baseline and 1, 6, 12, and 20 weeks after the first injection. Fluorescein angiography (FA) was performed before injection and 20 weeks after. The primary outcome measures were clearing of vitreous hemorrhage (VH) and regression of active fibrovascular tissue (FVT). The secondary outcomes were any change in best-corrected visual acuity (BCVA) and any incidence of adverse events.

RESULTS

Thirty eight eyes of 38 patients with a mean age of 54.7 +/- 10.1 years were included in the study. VH resolved significantly after 1 week (P = 0.014), 12 weeks (P = 0.0001), and 20 weeks (P = 0.002). The vascular component of FVT regressed, though the FVT area did not change. Mean BCVA improved significantly compared to baseline at all follow-up examinations. Two cases showing moderate fibrous proliferation developed traction retinal detachment (TRD).

CONCLUSIONS

IVB has significant therapeutic effect on eyes with active, progressive PDR: the treatment causes a significant amount of VH resolution and neovessel regression. At the same time, this procedure may increase the risk of TRD in eyes with fibrous proliferation.

A proposed new classification for diabetic retinopathy: the concept of primary and secondary vitreopathy

BACKGROUND

Many eyes with proliferative diabetic retinopathy (PDR) require vitreous surgery despite complete regression of new vessels with pan retinal laser photocoagulation (PRP). Changes in the vitreous caused by diabetes mellitus and diabetic retinopathy may continue to progress independent of laser regressed status of retinopathy. Diabetic vitreopathy can be an independent manifestation of the disease process.

AIM

To examine this concept by studying the long-term behavior of the vitreous in cases of PDR regressed with PRP.

MATERIALS AND METHODS

Seventy-four eyes with pure PDR (without clinically evident vitreous traction) showing fundus fluorescein angiography (FFA) proven regression of new vessels following PRP were retrospectively studied out of a total of 1380 eyes photocoagulated between March 2001 and September 2006 for PDR of varying severity. Follow-up was available from one to four years.

RESULTS

Twenty-three percent of eyes showing FFA-proven regression of new vessels with laser required to undergo surgery for indications produced by vitreous traction such as recurrent vitreous hemorrhage, tractional retinal detachment, secondary rhegmatogenous retinal detachment and tractional macular edema within one to four years.

CONCLUSION

Vitreous changes continued to progress despite regression of PDR in many diabetics. We identifies this as "clinical diabetic vitreopathy" and propose an expanded classification for diabetic retinopathy to signify these changes and to redefine the indications for surgery.

Vision-related quality of life and visual function following vitrectomy for proliferative diabetic retinopathy

PURPOSE

To evaluate the vision-related quality of life (VR-QOL) and visual function following vitrectomy for proliferative diabetic retinopathy (PDR).

DESIGN

Prospective, interventional, consecutive, comparative case series.

METHODS

The 25-Item National Eye Institute Visual Function Questionnaire (VFQ-25) was answered by 51 patients with PDR before and three months after 20-gauge pars plana vitrectomy. Among the patients with PDR, 30 underwent combined cataract surgery and vitrectomy. Clinical data were collected, including logarithm of minimal angle of resolution (logMAR) best-corrected visual acuity (BCVA), letter contrast sensitivity, and metamorphopsia. The VFQ-25 was also administered to 46 age-matched normal controls.

RESULTS

The preoperative VFQ-25 composite score was significantly lower in the PDR patients (56.3 +/- 18.8, mean +/- standard deviation) than in the normal controls (85.2 +/- 10.3; P < .0001). Vitrectomy significantly improved VFQ-25 composite score (P < .005) and eight of 12 subscales (P < .05). The preoperative VFQ-25 composite score significantly correlated with preoperative logMAR BCVA in the better-seeing eye (P < .001). The postoperative VFQ-25 composite score exhibited significant correlation with postoperative logMAR BCVA in the worse-seeing eye (P < .0001) as well as the better-seeing eye (P < .0001). Similar significant correlations were also observed between the VFQ-25 composite score and letter contrast sensitivity.

CONCLUSIONS

Vitrectomy for PDR significantly improves VR-QOL. The current study quantitatively indicates that VR-QOL in PDR patients depends on visual acuity and contrast sensitivity in the better-seeing eye preoperatively and in both the better-seeing and worse-seeing eyes postoperatively.

Outcome of diabetic vitrectomy in Latino population

PURPOSE

Evaluation of visual acuity and anatomic outcome in Latino patients undergoing vitrectomy for proliferative diabetic retinopathy, using silicone oil or gas tamponade.

METHODS

Retrospective review of 57 vitrectomies, 42 in Latino patients, performed by a single surgeon over a 3-year period.

RESULTS

Seventy-four percent of vitrectomies were on patients of Latino descent. Sixty-three percent of eyes had traction retinal detachments involving the macula. Overall, 29% in the Latino group received silicone oil tamponade, while the remainder received gas tamponade. In the gas treatment group, 16% developed rhegmatogenous detachments, while no rhegmatogenous detachments occurred in oil-treated eyes. This difference was not statistically significant. Follow-up ranged from 1 to 4 years (median, 1 year). The change from pre- to postsurgery visual acuity was calculated for both gas and oil treated groups, showing no statistically significant difference. Pre- and postsurgery visual acuity median was hand motions for both.

CONCLUSION

There was no statistically significant difference in final anatomic outcome or visual outcome in Latino eyes undergoing surgery for severe proliferative diabetic retinopathy. Silicone oil and gas tamponade appeared to work equally well in this population.

Evidence-based therapy of diabetic retinopathy

INTRODUCTION

Evidence-based medicine is often misunderstood as 'cookbook medicine with standard recipes' that does not take clinical experience into account. It is, however, supposed to be a basis for decision making in caring for individual patients under consideration of patients' preferences. This seems to be very important, since diabetic retinopathy continues to be the most frequent cause of vision loss in working age adults with negative consequences for patients' quality of life and for health economics.

MATERIALS AND METHODS

The most important evidence-based therapy for diabetic retinopathy and maculopathy is laser coagulation. Vitrectomy for proliferative stages has also been proven effective by clinical studies. For more recent treatment options like triamcinolone injection and vitrectomy for diabetic macular edema there is a lower level of evidence so far.

RESULTS

The Diabetic Retinopathy Study was the first to show the effectiveness of panfundus laser coagulation for a larger group of patients. The Early Treatment Diabetic Retinopathy Study in turn serves as a basis for laser coagulation of retinopathy and maculopathy. The Diabetic Retinopathy Vitrectomy Study could show the advantages of timely vitrectomy. Both the Diabetes Control and Complications Trial and the United Kingdom Prospective Diabetes Study could show the value of intensive blood glucose control.

DISCUSSION

Evidence-based medicine on the basis of the studies mentioned above is practiced quite self-evidently in ophthalmo-diabetology. It should be regarded as a helpful tool for special therapeutic situations which still leaves room for one's personal clinical experience to be included. It is somewhat problematic that the term evidence-based medicine seems to be restricted to the results of large randomized studies, because even special problems and very individual, difficult therapeutic questions can be placed on an evidence-based foundation, although at a lower level of evidence, using today's modern means of literature research.

Relative Cost of a Line of Vision in Age-Related Macular Degeneration

PURPOSE

To quantitate the relative cost of new therapies for age-related macular degeneration (AMD) versus saved vision.

DESIGN

Systematic review.

METHODS

Landmark AMD treatment studies were reviewed to quantitate the visual benefit. For comparison, representative treatment studies for common retinal conditions including retinal detachment, macular hole (MH), epiretinal membrane (ERM), and diabetic retinopathy were also reviewed.

MAIN OUTCOME MEASURES

Several parameters to estimate Snellen lines of vision saved were defined and tabulated for each condition. A regimen of office visits, ancillary testing, and treatments was outlined. Costs for this were tabulated using Medicare-allowable costs, and costs of visual benefit (per line of vision) for each condition were calculated. Life expectancy was factored in to calculate the cost of a line of vision for each year (line-year). The proportions of costs allocated to professional, technical, and pharmaceutical expenses were tabulated for each therapy.

RESULTS

The cost per line of vision saved for AMD therapies ranged from $997 for laser for extrafoveal choroidal neovascularization, to $5509 for photodynamic therapy for occult lesions, to $12 482 for pegaptanib injections. This compares to $651 for retinal detachment repair, $1658 for MH repair, $2411 for ERM peeling, $5458 for diabetic macular edema laser, $594 for panretinal photocoagulation, and $2984 to $4178 for diabetic vitrectomy. The costs per line-years ranged from $77 to $1248 for AMD, and $21 to $194 for the comparison conditions. The proportion of costs for pegaptanib treatment was 17% for professional fees and 70% for pharmaceutical fees. Assumptions incorporated in estimating costs for pegaptanib could easily have doubled because second-year costs might approximate first-year costs and the maintenance of treatment effect has not been well established.

CONCLUSIONS

Although correctly heralded as a breakthrough in macular degeneration treatment, new pharmacologic therapies for AMD are extremely expensive and some yield marginal visual dividends. As in all fields of medicine that provide care to elderly patients, these costs should be considered as they relate to health care costs for the individual patient and payors, and must be considered in a larger perspective of health care benefit apportionment.

Subthreshold diode micropulse panretinal photocoagulation for proliferative diabetic retinopathy

PURPOSE

To report the visual acuity and clinical outcomes of a pilot study of subthreshold diode micropulse (SDM) panretinal photocoagulation (PRP) for treatment of diabetic retinopathy.

METHODS

A retrospective chart review of all patients undergoing PRP for diabetic retinopathy between April 2000 and February 2003 was performed. Treated conditions ranged from severe non-proliferative to severe proliferative diabetic retinopathy. An SDM PRP protocol designed to avoid detectable laser lesions was employed. Treatment failure end points included the development of vitreous haemorrhage or the performance of vitrectomy.

RESULTS

Ninety-nine eyes of 63 patients undergoing SDM PRP were identified. Median follow-up was 1.0 year (range of 0.3-2.7 years). Treatment sessions per eye ranged from 1 to 6 (with a median of two sessions per eye). Overall visual acuity remained unchanged. The probability of treatment failure end points at 12 months post-treatment was 12.5% for vitreous haemorrhage and 14.6% for vitrectomy (from Kaplan-Meier survival analysis). Age, sex, diabetes type, and baseline retinopathy status were not significantly associated with the risk of either failure event. No treatment complications were observed. No eye demonstrated any laser lesion detectable clinically or by fluorescein angiography postoperatively.

CONCLUSION

SDM pan retinal photocoagulation minimized retinal damage and treatment complications in the management of high-risk non proliferative and proliferative diabetic retinopathy. Visual loss was prevented with a low rate of vitreous haemorrhage and vitrectomy postoperatively. Further study of the safety, efficacy, and optimal treatment parameters of SDM pan retinal photocoagulation for diabetic retinopathy is warranted.

Intravitreal bevacizumab (Avastin) for persistent new vessels in diabetic retinopathy (IBEPE study)

OBJECTIVE

To evaluate the short-term fluorescein angiographic and visual acuity effects of a single intravitreal injection of bevacizumab (Avastin) for the management of persistent new vessels (NV) associated with diabetic retinopathy.

METHODS

A prospective, nonrandomized open-label study of diabetic patients with actively leaking NV refractory to laser treatment and best-corrected Early Treatment Diabetic Retinopathy Study visual acuity (BCVA) worse than 20/40. Standardized ophthalmic evaluation was performed at baseline and at weeks 1, 6, and 12 (+/-1) following intravitreal injection of 1.5 mg of bevacizumab. Main outcome measures include changes in total area of fluorescein leakage from active NV and BCVA.

RESULTS

Fifteen consecutive patients (men, 9 [60%]; women, 6 [40%]) were included and all completed the 12-week follow-up period of the study. The mean +/- SD age of participants was 60.08 +/- 7.75 years (median, 59.5; range, 49-73 years). At baseline, mean +/- standard error of the mean (SEM) NV leakage area was 27.79 +/- 6.29 mm2. The mean +/- SEM area of active leaking NV decreased significantly to 5.43 +/- 2.18 mm2 and 5.50 +/- 1.24 mm2 (P < 0.05, Tukey multiple comparisons post-test) at 1 and 12 weeks postinjection, respectively; at week 6 no leakage was observed. The mean +/- SEM logMAR (Snellen equivalent) BCVA improved significantly from 0.90 (20/160) +/- 0.11 at baseline to 0.76 (20/125(+2)) +/- 0.12, 0.77 (20/125(+2)) +/- 0.11, and 0.77 (20/125(+2)) +/- 0.12 at weeks 1, 6, and 12, respectively (P < 0.05, Tukey multiple comparisons post-test). No major adverse events were observed.

CONCLUSIONS

Intravitreal injection of bevacizumab achieved short-term reduction of fluorescein leakage from persistent active NV without loss of vision in patients with diabetic retinopathy. Further studies to investigate the role of anti-VEGF therapy with bevacizumab for the management of diabetic retinopathy refractory to laser treatment are warranted.

Early vitreous surgery for aggressive posterior retinopathy of prematurity

PURPOSE

To assess the efficacy of early vitrectomy for aggressive posterior retinopathy of prematurity (ROP) to stop progression of retinal detachment.

DESIGN

Retrospective, noncomparative, consecutive case series.

METHODS

Twenty-two eyes (15 patients) with aggressive posterior ROP underwent vitrectomy with or without lens sparing, because retinal photocoagulation failed to stop progression of fibrovascular proliferation, despite being performed early, densely, and with early retreatment. We assessed the status of retinal attachment and foveal formation ophthalmoscopically and the presence or absence of fixation of visual behavior.

RESULTS

Follow-up ranged from six to 12 months (mean, 9 months). Six eyes (100%) in which a lens-sparing vitrectomy was performed developed a large tractional retinal detachment. In contrast, the retinas were completely reattached in 16 eyes (100%) in which vitrectomy with lensectomy was performed, nine eyes (56%) had foveal configuration, and 14 eyes (88%) had steady fixation.

CONCLUSIONS

These results suggest that early vitrectomy is effective for preventing retinal detachment in aggressive posterior ROP.

Comparative study of the polaroid and digital non-mydriatic cameras in the detection of referrable diabetic retinopathy in Australia

AIM

To show that the non-mydriatic retinal camera (NMRC) using polaroid film is as effective as the NMRC using digital imaging in detecting referrable retinopathy.

METHODS

A series of patients with diabetes attending the eye out-patients department at the Royal Victorian Eye and Ear Hospital had single-field non-mydriatic fundus photographs taken using first a digital and then a polaroid camera. Dilated 30 degrees seven-field stereo fundus photographs were then taken of each eye as the gold standard. The photographs were graded in a masked fashion. Retinopathy levels were defined using the simplified Wisconsin Grading system. We used the kappa statistics for inter-reader and intrareader agreement and the generalized linear model to derive the odds ratio.

RESULTS

There were 196 participants giving 325 undilated retinal photographs. Of these participants 111 (57%) were males. The mean age of the patients was 68.8 years. There were 298 eyes with all three sets of photographs from 154 patients. The digital NMRC had a sensitivity of 86.2%[95% confidence interval (CI) 65.8, 95.3], whilst the polaroid NMRC had a sensitivity of 84.1% (95% CI 65.5, 93.7). The specificities of the two cameras were identical at 71.2% (95% CI 58.8, 81.1). There was no difference in the ability of the polaroid and digital camera to detect referrable retinopathy (odds ratio 1.06, 95% CI 0.80, 1.40, P = 0.68).

CONCLUSION

This study suggests that non-mydriatic retinal photography using polaroid film is as effective as digital imaging in the detection of referrable retinopathy in countries such as the USA and Australia or others that use the same criterion for referral.

Innovations in eye surgery

The field of ophthalmology has undergone revolutionary changes during the past few decades. Advancements in understanding the pathophysiology of eye diseases, superior surgical instrumentation and surgeon skills, and cotreatment with medical therapies have enhanced outcomes. The geriatric population, preferentially affected by these illnesses, has seen a meaningful visual benefit from these surgical innovations. Most importantly, these improvements have led to increases in quality-of-life measures and mental and physical well-being of aging patients.

[Diabetic retinopathy]

Diabetic retinopathy is a frequently observed complication in both type 1 and type 2 diabetes, specially in patients with long term disease and poor glicemic control. Irreversible visual loss appears at the final stages of diabetic retinopathy and it is considered one of the most tragic of diabetic complications. It is also considered an important factor of morbidity and has a high economical impact once it is the leading cause of blindness. The pathophysiology of the retinal microvascular alterations is related to the chronic hyperglycemia that leads to the following circulatory disturbances: loss of vascular tonus, increase in vascular permeability, edema and exudation, with vascular obstruction and ischemia that stimulates neovascularization, which may lead to fibrous retraction and vitreous hemorrhages with retinal detachment. Recent studies have indicated that the strict glicemic and blood pressure controls are effective in reducing or blocking the progression of retinopathy. Up to now no pharmacological agents have shown to be effective in preventing or reducing neovascularization and visual loss. Presently, the most effective available treatment for proliferative retinopathy is laser photocoagulation. Further studies are needed to obtain new products and technologies that could effectively prevent or block retinopathy progression.

Pharmacological and pharmacokinetic study of olmesartan medoxomil in animal diabetic retinopathy models

A close relationship between the renin-angiotensin system and the pathophysiology of diabetic retinopathy has been suggested, several angiotensin II type 1 receptor (angiotensin AT1 receptor) antagonists being effective in animal models. Therefore, we examined the efficacy of an angiotensin AT1 receptor antagonist, olmesartan medoxomil (CS-866), in animal retinopathy models. In diabetic stroke-prone spontaneously hypertensive (SHRSP) rats, 4-week treatment with CS-866 prevented the elongation of oscillatory potential peaks dose-dependently which almost normalized at 3 mg/kg/day. Next, in oxygen-induced retinopathy mice, CS-866 at 1 mg/kg significantly prevented the retinal neovascularization. In these animal models, plasma concentrations of CS-866 were comparable to the in vitro IC50 value of the angiotensin AT1 receptor. In summary, our data demonstrated that CS-866 was effective in early and late stage retinopathy models through the inhibition of the angiotensin AT1 receptor. These findings suggest the possibility of CS-866 as a therapeutic agent for diabetic retinopathy.

Telehealth practice recommendations for diabetic retinopathy

Telehealth holds the promise of increased adherence to evidenced-based medicine and improved consistency of care. Goals for an ocular telehealth program include preserving vision, reducing vision loss, and providing better access to medicine. Establishing recommendations for an ocular telehealth program may improve clinical outcomes and promote informed and reasonable patient expectations. This document addresses current diabetic retinopathy telehealth clinical and administrative issues and provides recommendations for designing and implementing a diabetic retinopathy ocular telehealth care program. The recommendations also form the basis for evaluating diabetic retinopathy telehealth techniques and technologies. Recommendations in this document are based on careful reviews of current evidence, medical literature and clinical practice. They do not, however, replace sound medical judgment or traditional clinical decision-making. "Telehealth Practice Recommendations for Diabetic Retinopathy" will be annually reviewed and updated to reflect evolving technologies and clinical guidelines.

Chirurgische Therapie der diabetischen Retinopathie und Makulopathie

Surgical therapy of diabetic retinopathy has been refined since the Early Treatment Diabetic Retinopathy Study (ETDRS). ETDRS did not perform panretinal photocoagulation at the time of surgery, which is currently considered a major part of vitrectomy, e.g., in vitreous hemorrhage. Despite improved surgical techniques, patient expectations and surgical outcome still differ considerably in severe cases of proliferative diabetic retinopathy. In this review of the literature we discuss the current surgical options and indications in diabetic retinopathy and maculopathy.

Visual outcomes and complications after multiple vitrectomies for diabetic vitreous hemorrhage

PURPOSE

To determine the visual outcomes and complications after multiple vitrectomies for repeat diabetic vitreous hemorrhage.

METHODS

A retrospective review during a 4-year period of patients requiring multiple vitrectomies for nonclearing vitreous hemorrhages with at least a 6-month follow-up.

RESULTS

Of the 38 cases of multiple vitrectomies for diabetic vitreous hemorrhage, the initial visual acuity was 20/50 or better in 5%, between 20/60 and 20/400 in 37%, and worse than 20/400 in 58%. The final visual acuity after the last vitrectomy was 20/50 or better in 25%, between 20/60 and 20/400 in 47%, and worse than 20/400 in 28%. Patients had a mean improvement of 1.08 lines of visual acuity, and a statistically significant difference in logMAR visual acuity was noted when the last corrected visual acuity was compared with baseline acuity by way of paired t-testing. Although a trend toward visual improvement was noted in patients who underwent multiple vitrectomies, multivariate models failed to detect any association between number of surgeries or demographic variables and change in visual acuity.

CONCLUSION

Multiple vitrectomies for recurrent diabetic vitreous hemorrhage can have a favorable anatomic outcome while maintaining ambulatory vision.

Screening for diabetic retinopathy in France

Ocular complications of diabetes, particularly retinopathy, are the major cause of blindness in the working age population in industrialised nations. Laser photocoagulation has shown definite results in reducing visual morbidity with many more likely to benefit if diagnosed early enough. Institution of an efficient screening programme aimed at detecting patients at risk when they can still be effectively treated has been recognised as an urgent priority worldwide. In France, a signatory to the Saint Vincent's Declaration, an analysis of the national healthcare database reveals a gross inadequacy in the current extent of screening for diabetic retinopathy. The possible causative factors have been analysed and the necessary corrective measures, some of which are already under way, have been discussed. Ideally, screening by ophthalmologists at recommended intervals have been advised by national and professional health care associations. This has not been feasible owing to the lack of organised planning and serious manpower deficit caused by a progressive decline in the number of ophthalmologists. Recently, the need for an efficient, widely-available and user-friendly screening tool has led to the evaluation of multifield fundus photography in real time using digital nonmydriatic camera in comparison with more established methods of detecting diabetic retinopathy. Lastly, the future possibility of involving in France non-ophthalmologists like endocrinologists or general practitioner or non medical profession like orthoptists after proper training to meet the necessary manpower shortage has been addressed. Optimal use of telemedicine along with establishment of preferential reference channels for newly discovered cases of sight-threatening cases of retinopathy are public health priority necessary to give to the screening of diabetic retinopathy its full efficiency.