Risk Factors for Postoperative Hemorrhage after Vitrectomy for Diabetic Retinopathy

Investigation of the recurrent vitreous hemorrhage risk factors after early 25G vitrectomy in diabetic vitreous hemorrhage

Vitreous hemorrhage (VH) is one of the main causes of vision loss in diabetic retinopathy (DRP). Early surgery increases the visibility of the retina, allowing early recognition of DRP complications and additional treatments. One of the most important reasons affecting success after surgery is recurrent vitreous hemorrhage (RVH). We aimed to investigate the risk factors for RVH after early 25G vitrectomy in diabetic VH. Eighty eyes of eighty patients who underwent early 25G PPV surgery with a diagnosis of VH due to proliferative diabetic retinopathy (PDR) were included in this retrospective study. Vision acuity changes and intraocular pressure (IOP) changes were compared. The effect of arterial hypertension (HT), coronary artery disease (CAD), preoperative antiglaucomatous usage, and anticoagulant usage on RVH was investigated. A value of P < .05 was accepted as statistically significant. Postoperative RVH was observed in 18 (22.5%) patients. There was no correlation between the age of the patients and the development of postoperative RVH (r = -0.197, P = .08). The rate of HT and the mean HbA1C levels were found to be higher in the patients who developed RVH than in those who did not (P = .04 and < 0.001, respectively). The presence of CAD, preoperative glaucoma disease, and the use of anticoagulants did not have any effect on RVH (P = .229, 0.843, 0.932, respectively). HT and increased HbA1c were found to be risk factors for RVH in VH patients who underwent 25G vitrectomy in the early period in our study.

Functional and structural outcomes and complications after pars plana vitrectomy for severe features of proliferative diabetic retinopathy in type 1 and type 2 diabetes mellitus

PURPOSE

To evaluate the functional and structural outcomes as well as postoperative complications after pars plana vitrectomy (PPV) for severe features of proliferative diabetic retinopathy (PDR) in type 1 and type 2 diabetes mellitus (DM) patients.

METHODS

Twenty two eyes of type 1 diabetics (DM1 group) and 27 eyes of type 2 diabetics (DM2 group) were included. Best corrected visual acuity (BCVA), intraocular pressure (IOP), postoperative structural changes in optical coherence tomography (OCT) and postoperative complications such as recurrent vitreous haemorrhage, diabetic macular oedema, secondary glaucoma and persistent tractional retinal detachment (TRD) were assessed and compared between the two groups.

RESULTS

Complete reattachment of retina was achieved in 88.9% from the DM1 group and in 95.5% from the DM2 group and remained attached in follow-up. BCVA in DM2 group was significantly lower preoperatively (p = 0.04). Mean postoperative BCVA significantly improved in both studied groups, but it was more evident in eyes of type 2 diabetics compared to type 1 diabetics. In eyes in the DM1 group there was perceptible stabilisation of BCVA. Poor visual acuity or lack of improvement in BCVA in the DM1 group was related to preoperative subretinal haemorrhage in macular region, and TRD involving macula, whereas in the DM2 group-to preoperative subretinal haemorrhage and neovascular glaucoma. The postoperative structural changes (disruption of EZ and ELM) were observed more often in DM2 group, but had the greatest impact on BCVA in eyes of type 1 DM. Complications after PPV for PDR were rare and hadn't a significant influence on the final functional outcomes in both groups.

CONCLUSIONS

Functional improvement after PPV for severe features of proliferative diabetic retinopathy were more noticeable in patients with type 2 DM. Postoperative structural changes had more negative impact on BCVA in type 1 diabetics.

A pilot study of viscoelastic agent to prevent recurrent vitreous hemorrhage after vitrectomy for proliferative diabetic retinopathy

BACKGROUND

To evaluate the possibilty of preventing recurrent vitreous hemorrhage (RVH) after vitrectomy in proliferative diabetic retinopathy (PDR) patients with unabsorbed vitreous hemorrhage (VH) by intravitreal injection of viscoelastic agent (VA) at the end of the surgery and compared its effect with triamcinolone acetonide (TA).

METHODS

This was a pilot prospective, observational study. PDR patients with VH who underwent vitrectomy were assigned to 3 groups according to the tamponade applicated at the end of the surgery, including VA group (intravitreally injected 1 ml VA if the retina was prone to bleed during the operation), TA group (intravitreally injected 2 mg TA when there was much exudates), or balanced salt solution (BSS) group (no tamponade). Then postoperative follow-up was performed routinely until 6 months after surgery. The primary outcome was the incidence of RVH, secondary outcome were the best-corrected visual acuity (BCVA) and introcular pressure (IOP). Cataract formation and other complication were also assessed.

RESULTS

A total of 68 eyes, from 68 patients, were included. 18,18,32 eyes were enrolled in the VA group, TA group and BSS group, respectively. The integral incidence of RVH after vitrectomy was 5.6%, 5.6% and 12.5% respectively (P = 0.602). There was no early RVH in VA or TA group, whereas 3 early RVHs were identified in BSS group, however there was no significant difference (P = 0.171). Every group had one late RVH case. In all groups, final BCVA showed significant improvement compared to baseline. BCVA at any postoperative visit showed no significant differences among 3 groups. Mean IOP was higher 1 week after surgery in VA group compared with the other groups; however, in other times the differences were not significant. No cataract formation and other complication was noted in 3 groups.

CONCLUSION

Intravitreal injection of VA or TA at the end of vitrectomy for PDR patients with unabsorbed VH tend to reduce the incidence of early RVH after vitrectomy similarly. As VA was preferred to applicate in the eyes that were prone to bleed, intravitreal injection of VA at the end of vitrectomy might be a promising method for preventing RVH in PDR patients.

Visual outcomes and complications following one-way air-fluid exchange technique for vitreous hemorrhage post vitrectomy in proliferative diabetic retinopathy patients

BACKGROUND

To evaluate the efficacy and outcomes of one-way surgical technique for the treatment of vitreous hemorrhage post vitrectomy on proliferative diabetic retinopathy (PDR) patients.

METHODS

This retrospective case series include 47 PDR patients who had vitrectomy with balanced saline solution tamponade and have developed vitreous hemorrhage without significant absorption. The one-way air-fluid exchange procedure which involves the application of a 0.22-μm pore size filter to exchange about 4.5-5.5 ml of fluid with a 10 ml syringe was performed on 47 patients (47 eyes). Post procedure, additional treatments were administered when needed. Best corrected visual acuity (BCVA), occurrence of intra-procedural and post-procedural complications were recorded and analyzed.

RESULTS

A total of 47 eyes of 47 PDR patients with a mean age of 50.8 ± 12.0 years were reviewed. Because of vitreous hemorrhage or tractional retinal detachment of PDR, all 47 eyes underwent vitrectomy with balanced saline solution tamponade prior to the exchange procedure. Four patients (8.51%) and 43 patients (91.5%) were diagnosed with type 1 diabetes mellitus (T1DM), or type 2 diabetes mellitus (T2DM), respectively. All 47 eyes were given the one-way air-fluid exchange procedure in the treatment room. Forty-two cases (89.4%) needed the air-fluid exchange procedure only once, 4 cases (8.51%) underwent the procedure twice, and 1 case (2.13%) was given the procedure three times, followed by additional retinal photocoagulation and one intravitreal injection of Conbercept. In addition to the procedure, no further treatment was needed for 5 eyes (10.6%) while additional retinal laser treatment was provided for 41 eyes (87.2%). The BCVA at the final follow-up was significantly improved from the initial acuity baseline in all cases. No complications were observed during the follow-ups.

CONCLUSION

This one-way air-fluid exchange procedure can effectively exchange the vitreous hemorrhage and improve visual acuity of PDR patients who develop vitreous rehemorrhage post vitrectomy without obvious complications.

Current management of diabetic tractional retinal detachments

Twenty-five percent of diabetes-related vision loss stems from complications of proliferative diabetic retinopathy (PDR). Panretinal photocoagulation has been the preferred treatment of high-risk PDR for decades and more recently intravitreal injections of drugs that inhibit the actions of vascular endothelial growth factor have become popular. But despite these treatments PDR may progress uncontrollably to advanced pathologies such as traction retinal detachments (TRDs), combined traction/rhegmatogenous retinal detachments (TRD/RRDs), vitreous hemorrhages, rubeosis iridis, and traction maculopathies, which produce mild-to-severe loss of vision. TDR have long been the most common indication for PDR-related vitreoretinal surgery. Vitrectomy surgery is indicated for recent (<6 months duration) TRD involving the macula, progressive TRD that threatens the macula, and recent data suggest that chronic macula-involving TRDs (>6 months duration) may also benefit. Combined TRD/RRD represents a particularly challenging surgical condition but advances in surgical instrumentation, dissection techniques, and post-operative tamponade have produced excellent success rates. The recent development of small-gauge vitrectomy systems has persuaded most surgeons to switch platforms since these appear to produce shorter surgical times and quicker post-operative recoveries. Pre-operative injections of bevacizumab are frequently administered for persistent neovascularization to facilitate surgical dissection of pre-retinal fibrosis and reduce the incidence of post-operative hemorrhages. Recent trends toward earlier surgical intervention and expanded indications are likely to continue as surgical instrumentation and techniques are further developed.

Twenty-seven-gauge vitrectomy for combined tractional and rhegmatogenous retinal detachment involving the macula associated with proliferative diabetic retinopathy

Background

To report our experience using 27-gauge pars plana vitrectomy (PPV) system for treating patients with combined tractional and rhegmatogenous retinal detachments (CTRRD) involving the macula associated with proliferative diabetic retinopathy (PDR).

Methods

Retrospective noncomparative interventional cases series of 12 patients with CTRRD associated with PDR who underwent 3-port, transconjunctival 27-gauge PPV by a single surgeon. Main outcome measures were change in Snellen best corrected visual acuity (BCVA) and occurrence of intra- and post-operative complications.

Results

Twelve eyes from 12 patients (9 men and 3 women) underwent 27-gauge PPV. Mean follow-up was 17 months (range 8–26 months). Preoperatively, BCVA of 20/400 or better was recorded in only 2 of 12 (16.7%) eyes. Postoperatively, BCVA improved to 20/400 or better in 11 of 12 (91.7%) eyes at 6 months (P = 0.001). At last follow-up, BCVA of 20/400 or better was recorded in 10 of 12 (83.3%), in comparison to 2 (16.7%) eyes at baseline (P = 0.004). The only intraoperative complication was an iatrogenic break in 1 eye (8.3%). Postoperative complications included vitreous hemorrhage in 4 eyes (33.3%) and transient ocular hypertension in 3 eyes (25.0%). At final follow-up anatomic success was confirmed in all eyes.

Conclusion

The current study findings suggest that 27-gauge PPV is a safe and promising surgical technology for treating patients with CTRRD involving the macula associated with PDR. Smaller gauge instruments and higher cutting rates may facilitate the dissection and shaving of fibrovascular membranes, while minimizing intra- and post-operative complications.

Electronic supplementary material

The online version of this article (doi:10.1186/s40942-017-0091-x) contains supplementary material, which is available to authorized users.

Comparison of clinical outcome between 23-G and 25-G vitrectomy in diabetic patients

PURPOSE:

To compare the clinical outcomes and complications between 23-G and 25-G vitrectomy in patients with diabetic vitreous hemorrhage (VH).

MATERIALS AND METHODS:

A retrospective comparative study comprising 69 eyes (36 eyes in 23-G group and 33 eyes in 25-G group) of 65 patients who underwent vitrectomy with air tamponade for diabetic vitreous hemorrhage (VH) with at least 6 months of follow-up was conducted.

RESULTS:

There were no significant differences between the two groups in age, gender, bilaterality, type of diabetes, presence of hypertension, lens status, and previous argon laser photocoagulation state (P > 0.05). Best-corrected visual acuity (BCVA) of both groups at postoperative 1 month logarithm of the minimum angle of resolution (logMAR) (1.06 ± 0.99, 0.90 ± 0.96), 3 months logMAR (1.07 ± 0.93, 0.83 ± 0.85), and 6 months logMAR (1.03 ± 0.89, 0.83 ± 0.85) significantly improved from the preoperative BCVA logMAR (2.03 ± 0.83, 2.15 ± 0.99) for 23-G group, 25-G group, respectively (P < 0.0001). There was no significant difference in BCVA between the two groups preoperatively and at 1, 3, and 6 months postoperatively (P = 0.566, 0.506, 0.333, and 0.445, respectively), incidence of intraoperative wound suturing (21.4%, 15.2%), postoperative hypotony (0.0%, 0.0%), early postoperative VH (POVH) (11.1%, 15.2%), late POVH (5.6%, 0.0%), retinal detachment (2.8%, 6.1%), neovascular glaucoma (92.8%, 9.1%), and endophthalmitis (0.0%, 0.0%) for 23-G group, 25-G group, respectively (P > 0.05).

CONCLUSION:

25-G vitrectomy is as effective for PDR as 23-G vitrectomy.

Intravitreal Ranibizumab Injection as an Adjuvant in the Treatment of Neovascular Glaucoma Accompanied by Vitreous Hemorrhage after Diabetic Vitrectomy

Purpose. To determine the efficacy of intravitreal ranibizumab injection as adjuvant therapy in the treatment of neovascular glaucoma (NVG) accompanied by postvitrectomy diabetic vitreous hemorrhage (PDVH). Methods. Eighteen NVG patients (18 eyes) accompanied by PDVH were enrolled in this prospective, monocenter, 12-month, interventional case series. The consecutive 18 patients with an IOP ≥ 25 mmHg despite being treated with the maximum medical therapy were treated with intravitreal ranibizumab injections. Vitreous surgery or/with Ahmed valve implantation were indicated if no clinical improvement in vitreous haemorrhage and uncontrolled IOP was shown. Results. Ten patients got clear vitreous and controlled IOP only with 2.7 ± 1.8 injections of ranibizumab without additional surgery. Vitrectomy or/with Ahmed valve implantation was administered in the other 8 eyes due to uncontrolled VH and IOP. At follow-up month 12, all the 18 eyes gained clear vitreous. At month 12 BCVA improved significantly compared to baseline. The baseline and follow-up at month 12 IOP/medication usage were 36.7 ± 8.1 mmHg on 3.4 ± 0.7 medications and 16.2 ± 4.9 mmHg on 0.67 ± 0.77 medications, respectively. Conclusions. The findings suggest that intravitreal ranibizumab injection as adjuvant therapy for treatment of NVG accompanied by PDVH may be safe and potentially effective. This clinical trial is registered with NCT02647515.

The role of intraoperative bevacizumab for prevention of postoperative vitreous hemorrhage in diabetic vitreous hemorrhage

PURPOSE

To assess the effect of intravitreal bevacizumab (IVB) on the incidence of postoperative recurrent vitreous hemorrhage (VH) in eyes operated for diabetic VH when injected at the end of the surgery.

METHODS

A prospective, comparative clinical trial was conducted on a consecutive series of patients requiring vitrectomy for diabetic nonclearing VH. Intravitreal bevacizumab (2.5 mg/0.1 mL) was injected at the completion of surgery. Patients underwent best-corrected visual acuity (VA), applanation tonometry, and biomicroscopic anterior and posterior segment evaluation for VH grading. Postoperative visits were performed at the first day, first week, first month, third month, and sixth month. The VH was graded at each visit, and the rate of postoperative VH and VA improvement and potential complications were evaluated and compared between the groups.

RESULTS

A total of 72 eyes of 66 patients were included. Thirty-four eyes were enrolled in the IVB group and 38 eyes were enrolled in the control group. The rate of postoperative VH did not differ significantly between the groups at any postoperative visit (p>0.05). Three eyes (8.8%) in the IVB group and 5 eyes (13.1%) in the control group had postoperative VH throughout the follow-up period and only one eye from each group underwent a second surgery. Postoperative VA significantly increased in both groups but did not differ significantly between the groups at any postoperative visit (p>0.05).

CONCLUSIONS

Intravitreal bevacizumab does not seem to have any beneficial effect on the incidence of postoperative VH in eyes operated for diabetic VH when injected at the end of surgery.

Vitreous hemorrhage after the 25-gauge transconjunctival sutureless vitrectomy for proliferative diabetic retinopathy

PURPOSE

To address the incidence, clinical course, and risk factors for postoperative vitreous hemorrhage (PVH) after a 25-gauge transconjunctival sutureless vitrectomy for proliferative diabetic retinopathy.

METHODS

A consecutive series of eyes underwent 25-gauge transconjunctival sutureless vitrectomies for proliferative diabetic retinopathy. The best-corrected visual acuities and intraocular pressures were measured, and the complications were prospectively evaluated 1 day, 1 week, 1 month, and 3 months postoperatively, then as needed.

RESULTS

The mean postoperative follow-up was 11.0 ± 6.3 months (range, 6-28 months). Of 93 eyes, 42 had PVH on Day 1 (immediate PVH) but the presence and degree of PVH did not affect visual recovery and only 4 eyes did not clear for 1 month (persistent PVH). Recurrent PVH occurred in 11 eyes. Eight eyes had hypotony on Day 1, and patients who experienced postoperative hypotony had an 11.20-fold increased risk of immediate PVH > Grade 2. In the cases that needed intravitreal tamponade, the risk of recurrent PVH was 3.03-fold higher.

CONCLUSION

After 25-gauge transconjunctival sutureless vitrectomies for proliferative diabetic retinopathy, postoperative hypotony and the need for tamponade increased the rates of immediate and recurrent PVH, respectively. Immediate PVH occurred in 45.2% of the patients but did not affect early visual recovery. A 25-gauge transconjunctival sutureless vitrectomy resulted in a favorable incidence of recurrent PVH (11.8%) during the first 6 months.

[Use of silicone oil in vitreal hemorrhage complicating proliferated diabetic retinopathy]

INTRODUCTION

Vitreous hemorrhage is a frequent complication of proliferated diabetic retinopathy. Vitrectomy has vastly improved its prognosis. The purpose of this study was to evaluate the use of silicone oil in vitreal surgery in this indication.

METHODS

We present a retrospective study of 15 eyes that underwent vitrectomy and silicone oil injection for vitreal hemorrhage complicating proliferative diabetic retinopathy. For each patient, we noted the clinical and echographic features, the surgical procedure, and the postoperative outcome after a mean period of 20 months.

RESULTS

The indications for silicone injection were recurrent vitreal hemorrhage (seven eyes), aggressive fibrovascular proliferations (five eyes), and iatrogenic retinal breaks (three eyes). Anatomic success was noted in ten cases. Four patients had a hemorrhage reoccurrence after silicone oil removal and one patient developed neovascular glaucoma. Silicone cataract (seven eyes) and emulsification of silicone (one eye) were noted.

DISCUSSION

The use of silicone oil in vitreal surgery for complicated proliferated diabetic retinopathy contributes a hemostatic and plugging effect, but it still has a number of disadvantages such as the need to remove it and its own side effects. It can be beneficial in cases of rubeosis or recurrent hemorrhage. However, it is essentially indicated in recurrent hemorrhage in monophthalmos patients.

Diabetic vitrectomy: risks, prognosis, future trends

PURPOSE OF REVIEW

We review the current standards, risks, prognosis, and indications for diabetic pars plana vitrectomy and consider recent developments in surgical techniques. We also examine surgery's role as a treatment modality for diabetic eye disease among the other accepted and developing treatment options, such as systemic and intravitreal pharmacotherapy.

RECENT FINDINGS

Pars plana vitrectomy for diabetic macular edema and for traction retinal detachment is addressed. Techniques to decrease retinal swelling and ischemia are showing promising results. The use of the smaller 25-gauge and 23-gauge vitrectors is gaining acceptance and offers advantages such as less trauma, less postoperative discomfort, and quicker healing. Techniques are being developed and refined to help prevent postoperative vitreous hemorrhage using cryotherapy around sclerotomy sites and/or endolaser in a near-confluent pattern in an effort to quell fibrovascular ingrowth and subsequent hemorrhage. Finally, pharmacological advances include targeting three levels of intervention: achieving the best glycemic control, correcting altered retinal metabolism secondary to increased glucose availability, and employing neuroprotective and vasoprotective agents.

SUMMARY

The combination of therapies and interventions as they improve and evolve offers the potential to revolutionize the approach to the complications of diabetic eye disease and may soon render many current interventions obsolete. Diabetic pars plana vitrectomy continues to advance with better anatomic and visual success.