Four-port bimanual 23-gauge vitrectomy for diabetic tractional retinal detachment

[Outcomes of bimanual vitreoretinal surgery in the treatment of diabetic retinopathy complications]

The incidence of diabetic retinopathy (DR) requiring vitreorentinal surgery is increasing. The search for new effective and safe methods of treatment, the choice of the optimal time for surgery, and the assessment of long-term treatment outcomes are relevant problems.

PURPOSE

This study evaluates the long-term results of vitreorentinal surgery using the bimanual technique in DR with different stages of fibrovascular proliferation.

MATERIAL AND METHODS

The study included 135 patients (135 eyes) who were divided into groups depending on the predominant type of proliferation - vascular or fibrous. Patients underwent vitrectomy with membranectomy using the bimanual technique, with peripheral panretinal endolaser coagulation of the retina and tamponade of the vitreous cavity with balanced salt solution. The postoperative observation period lasted up to 12 months.

RESULTS

Both groups showed statistically significant improvement in visual function and anatomical changes in central retinal thickness. A statistically significant improvement in best corrected visual acuity (BCVA) was found in patients with initially predominantly vascular proliferation. Correlation analysis showed that initially higher BCVA tends to persist in the postoperative period. A negative correlation was found between the final BCVA and the presence of type 2 diabetes mellitus, fibrous stage of proliferation, high central retinal thickness, and the presence of diabetic macular edema (DME) - both initially and after treatment. The frequency of complications in the groups was comparable, except for postoperative DME, which was more often detected in patients with fibrous proliferation.

CONCLUSION

The bimanual technique of vitreorentinal surgery for complications of DR allows achieving high anatomical and functional results. Higher BCVA is noted in patients with the vascular stage of proliferation and initially high BCVA. The obtained data allow us to form a hypothesis about the possibility of earlier surgery in patients with high BCVA, but require further investigation.

Fibroblast Growth Factor Type 1 Ameliorates High-Glucose-Induced Oxidative Stress and Neuroinflammation in Retinal Pigment Epithelial Cells and a Streptozotocin-Induced Diabetic Rat Model

Diabetic retinopathy (DR) is a common complication of diabetes that causes severe visual impairment globally. The pathogenesis of DR is related to oxidative stress and chronic inflammation. The fibroblast growth factor type 1 (FGF-1) mitogen plays crucial roles in cell function, development, and metabolism. FGF-1 is involved in blood sugar regulation and exerts beneficial antioxidative and anti-inflammatory effects on various organ systems. This study investigated the antioxidative and anti-inflammatory neuroprotective effects of FGF-1 on high-glucose-induced retinal damage. The results revealed that FGF-1 treatment significantly reversed the harmful effects of oxidative stress and inflammatory mediators in retinal tissue in a streptozotocin-induced diabetic rat model. These protective effects were also observed in the in vitro model of retinal ARPE-19 cells exposed to a high-glucose condition. We demonstrated that FGF-1 attenuated p38 mitogen-activated protein kinase and nuclear factor-κB pathway activation under the high-glucose condition. Our results indicated that FGF-1 could effectively prevent retinal injury in diabetes. The findings of this study could be used to develop novel treatments for DR that aim to reduce the cascade of oxidative stress and inflammatory signals in neuroretinal tissue.

The incidence and risk factors of neovascular glaucoma secondary to proliferative diabetic retinopathy after vitrectomy

OBJECTIVE

The incidence and risk factors of neovascular glaucoma (NVG) secondary proliferative diabetic retinopathy (PDR) after pars plana vitrectomy (PPV) are unclear and reports in the published literature are inconsistent. Therefore, a systematic review and meta-analysis were conducted to clarify the risk factors associated with neovascular glaucoma.

METHODS

PubMed, Embase, and The Cochrane Library were systematically searched without language limitations for studies related to NVG after PPV in PDR patients. We used R software to fit the correlation between incidence and the date of publication for studies and performed a Spearman analysis. For binary and continuous variables, the odds ratios (ORs) with 95% confidence intervals (CIs) were pooled, respectively, using Review Manager 5.3 (The Cochrane Collaboration).

RESULTS

Twenty-six studies with 5161 patients were included in our meta-analysis. The overall pooled incidence of NVG after PPV in PDR patients was 6% (95% CI, 0.05-0.07, p-value < 0.00001). Pooled estimates indicated a positive correlation for NVG after PPV in PDR patients with higher baseline IOP (OR, 1.26; 95%CI,0.56-1.95, p-value = 0.0004), preoperative iris neovascularization (INV) (OR, 5.66; 95% CI, 2.10-15.23, p-value = 0.0006), preoperative or intraoperative combined cataract surgery (OR, 2.00; 95% CI, 1.15-3.46, p-value = 0.01), postoperative vitreous hemorrhage (VH) (OR, 3.53; 95% CI, 1.63-7.66, p-value = 0.001), and a negative correlation with age (OR, -2.90; 95%CI, -5.00 to -0.81, p-value < 0.007).

CONCLUSION

Our systematic review and meta-analysis indicated that the main risk factors for NVG after PPV in PDR patients included higher baseline IOP, preoperative INV, preoperative or intraoperative combined cataract surgery, postoperative VH, and was negatively correlated with age.

Intraoperative optical coherence tomography and proportional reflux hydrodissection-guided pars plana vitrectomy for complex severe proliferative diabetic retinopathy

The study describes the technique of combining microscope-integrated optical coherence tomography (mi-OCT) and proportional reflux hydrodissection (PRH) during pars plana vitrectomy (PPV) in eyes with complex proliferative diabetic retinopathy (PDR) including tractional retinal detachment (TRD), combined retinal detachment (CRD), and taut posterior hyaloid membrane (TPHM). In this technique, PRH is used to create tissue planes between fibrovascular adhesions in areas identified using mi-OCT for insinuating the vitrector, enabling tissue dissection and release of traction. About 46 patients were operated using this technique. 34 eyes had TRD, 9 eyes had CRD, and 3 eyes were diagnosed with TPHM. A second instrument was used only in nine eyes. None of the eyes required use of intraocular scissors. Iatrogenic breaks occurred in six eyes. All patients had successful reattachment at 3-month follow-up. Thus, combination of mi-OCT and PRH is useful incomplete fibrovascular tissue dissection during PPV for complex PDR cases.

Prognostic factors of revitrectomy for complications in eyes with proliferative diabetic retinopathy: a retrospective multicentre study

PURPOSE

To identify prognostic factors for revitrectomy in patients who underwent vitrectomy for complications with proliferative diabetic retinopathy (PDR) in multicentre study.

METHODS

Consecutive 452 eyes of 452 patients with PDR undergoing 25-gauge microincision vitrectomy system (MIVS) in seven centres were retrospectivity reviewed. Preoperative ocular factors (baseline visual acuity [VA], vitreous haemorrhage [VH], tractional retinal detachment [TRD] and retinal photocoagulation), general factors (sex, age, diabetes duration, HbA1c level, hypertension, anti-coagulant medication and estimated glomerular filtration rate), surgical procedures (preoperative anti-vascular endothelial growth factor injection, internal limiting membrane peeling, combined cataract surgery, retinal break, and tamponade), postoperative complications for revitrectomy and postoperative VA at 6 months were evaluated.

RESULTS

In the follow-up period of 6 months, revitrectomy was performed in 56 eyes (26.3%), and postoperative complications for revitrectomy were VH in 31 eyes (15%), TRD in 13 eyes (6.2%) and membrane proliferation in 12 eyes (5.2%). The mean LogMAR improvement from baseline to 6 months in revitrectomy group (0.39) was significantly worse than in single vitrectomy group (0.74). Diabetic duration, low baseline VA, less simple VH, TRD and air tamponade were statistical risk factors of revitrectomy, and logistic regression analysis identified low baseline VA and air tamponade also as prognostic factors of revitrectomy.

CONCLUSION

Our results indicated that prognosis of VA was worse in PDR patients with revitrectomy and low baseline VA and air as the tamponade material were the potential prognostic factors of revitrectomy.

Outcomes of vitrectomy for diabetic tractional retinal detachment in Chicago's county health system

PURPOSE

To examine outcomes of 23-gauge (23G) pars plana vitrectomy (PPV) for complex diabetic tractional retinal detachment (TRD) in Chicago's Cook County Health and Hospitals System (CCHHS).

MATERIALS AND METHODS

This is a retrospective noncomparative study of diabetic TRD cases that underwent PPV at CCHHS. Primary retinal reattachment rate, visual function, and postoperative complications were analyzed.

RESULTS

Sixty nine consecutive cases were included. Primary reattachment and final attachment were achieved in 68/69 eyes (98.6%). Secondary retinal detachment was noted in 1 eye (1.4%). Vitreous hemorrhage requiring repeat PPV developed in 5 eyes (7.2%) and reoperation due to other complications was required in 4/69 eyes (5.8%). Perfluoropropane (C3F8) gas tamponade was used in 91.3% of eyes and silicone oil in 8.7% of eyes. Mean LogMAR visual acuity significantly improved from 1.84 ± 0.61 to 0.93 ± 0.66, (P<0.0001). Vision was stabilized or improved in 66 eyes (95.7%). Visual acuity of 20/200 or better was achieved in 49/69 eyes (71.0%) and 20/50 or better in 16/69 eyes (23.2%).

CONCLUSIONS

Even in patients with severe and advanced diabetic TRD pathology and unique demographics as seen in CCHHS, modern vitrectomy techniques can provide excellent anatomical and visual outcomes.

A Two Forceps Technique For Approaching Tractional Diabetic Membranes

BACKGROUND AND OBJECTIVE

To describe a two-forceps bimanual approach for complex diabetic detachments.

PATIENTS AND METHODS

Curved scissors were used to create a zone of decreased resistance within a thick fibrovascular membrane in a previously vitrectomized patient. Using two forceps, the linear defect was propagated into the periphery in a direction tangential to the retina. The tissue was repeatedly regrasped at the leading edge of the propagating tear, allowing for progressive separation of the hyaloid from the retinal surface.

RESULTS

Separation of the diabetic membrane and hyaloid from the retinal surface in a previously vitrectomized patient.

CONCLUSION

The authors describe a two-forceps approach for dense fibrovascular proliferation in the setting of persistently attached cortical vitreous that may be employed in cases of severe diabetic retinopathy with traction and fibrovascular membranes, even after previous vitrectomy. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:e176-e178.].

Surgical management of diabetic tractional retinal detachments

Tractional retinal detachment is an end-stage form of diabetic retinopathy that occurs when contractile forces in the vitreous and neovascular tissue lead to the detachment of the neurosensory retina. We review the literature related to the management of this disease. Preoperative planning includes appropriate patient selection, diagnostic and prognostic imaging, and medical optimization with reduction of systemic risk factors. Use of antivascular endothelial growth factor for preoperative treatment has had significant benefits for tractional retinal detachment repair in improving surgical efficiency and outcomes. Advances in microsurgical instrumentation are discussed, with attention to small-gauge vitrectomy with improved flow dynamics, viewing strategies, and lighting allowing bimanual surgery. Special emphasis is placed on bimanual surgical technique, choice of tamponade, and the avoidance of iatrogenic damage. Complications and special considerations are further explored. Based on our compilation of relevant literature, we propose a surgical algorithm for the management of these complex patients.

Effect of three-dimensional reconstruction-assisted 23G micro-invasive vitrectomy in patients with proliferative diabetic retinopathy

In the present study, we investigated the effect of optical coherence tomography (OCT) three-dimensional reconstruction-assisted 23G micro-invasive vitrectomy (abbreviated to'23G') in patients with proliferative diabetic retinopathy (PDR). A total of 66 PDR patients (66 eyes) were continuously selected and randomly divided into the control and observation groups with 33 patients in each group. Patients in the control group were treated with routine OCT examination while the patients in the observation group were treated with OCT three-dimensional retinal reconstruction. The 23G surgical method was applied to the two groups, and a comparison was made on the clinical effects in the two groups. The follow-up visits lasted for approximately 6 months, and it was found that the operative time, occurrence rate of intraoperative complications and postoperative complications as shown in the observation group were significantly less than those in the control group (P<0.05). The best corrected visual acuity (BCVA) was improved, the intraocular pressure was increased and retinal thickness was decreased after the treatment. The BCVA of patients in the observation group was significantly greater than that of patients in the control group while the intraocular pressure and retinal thickness of patients in the observation group were significantly less than those of patients in the control group (P<0.05). In conclusion, the effect of 23G surgical method in PDR patients can be improved and corresponding complications can be reduced under the assistance of OCT three-dimensional reconstruction.

A Review of Innovations in Rhegmatogenous Retinal Detachment Surgical Techniques

Rhegmatogenous retinal detachment (RRD) requires surgical intervention for its repair. There are variable techniques used for this purpose, and they are all being continuously refined. In this review, we detail the recent innovations in surgical management of RRD and proliferative vitreoretinopathy (PVR).