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

Effect of ILM Peeling on Anatomical and Visual Outcomes in Diabetic Tractional Retinal Detachment

Objectives

The objcetive is to compare the anatomic and functional outcomes of vitrectomy between internal limiting membrane (ILM) peeling and non-ILM peeling in diabetic tractional retinal detachment (TRD).

Methods

Twenty-three eyes with diabetic TRD with ILM peeling were compared with twenty-four eyes with non-ILM peeling. Best-corrected visual acuity (BCVA) was recorded at baseline and 3, 6, 9, 12 months, and end of follow-up. The mean retinal thickness across nine different regions that defined in the Early Treatment Diabetic Retinopathy Study (ETDRS) were obtained. The ETDRS grid was used to determine the extent of macular involvement.

Results

In the 1st month postoperatively, the mean BCVA of eyes with ILM peeling (1.08±0.63 LogMAR) was significantly better than eyes with ILM non-peeling (1.69±0.75 LogMAR, p=0.003). There was also a significant difference at 9 and 12 months between groups in BCVA, in favor of ILM peeling (p=0.012 and p=0.047, respectively). Seven patients (29.2%) developed epiretinal membrane (ERM), and one patient (4.1%) had ERM with the lamellar macular hole in the ILM non-peeling group, while only one patient developed ERM in ILM peeling group during the follow-up.

Conclusion

ILM removal may be considered in diabetic TRD surgery, as it can provide rapid visual recovery. Moreover, post-operative ERM formation was less frequent in ILM peeled eyes within 1 year after surgery.

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.

Clinical Outcomes of 27-Gauge Pars Plana Vitrectomy for Diabetic Tractional Retinal Detachment Repair

Purpose: To analyze the clinical outcomes of 27-gauge pars plana vitrectomy (PPV) repair of diabetic tractional retinal detachment (TRD) of various severities. Methods: This retrospective case series examined the outcomes of 27-gauge PPV to repair diabetic TRD from 2016 to 2020. The effect of medical and ophthalmologic history parameters and baseline detachment characteristics on visual acuity (VA) and retinal reattachment was analyzed. A grading system was established to stage the severity of the baseline vitreoretinal traction or detachment and compare the visual and anatomic outcomes between stages. Results: The study comprised 79 eyes (79 patients). The overall redetachment rate was 10.1% (8/79). The proportion of eyes with severe visual impairment (worse than 20/200) decreased from 81.0% (64/79) preoperatively to 56.9% (37/65) 6 months postoperatively (P < .001). Worse preoperative logMAR VA was associated with greater odds of redetachment (P = .017) and worse postoperative VA (P < .001). Insulin dependence was associated with better VA at 6 months (P = .017). A shorter known duration of diabetes (P = .026) and evidence of neovascularization of the iris (NVI) or angle (P = .004) were associated with worse visual outcomes. Eyes with detachment involving the posterior pole extending beyond the equator had worse VA at 6 months (P = .048). Conclusions: The primary reattachment rate after 27-gauge PPV was 89.9%. There was significant VA improvement, with a roughly 40% reduction in the number of eyes with severe visual impairment by the final follow-up. Insulin dependence, duration of diabetes, presence of NVI before surgery, and baseline posterior pole detachment extending beyond the equator were predictors of visual outcomes.

Safety and effectiveness of pre-emptive diabetic vitrectomy in patients with severe, non-fibrotic retinal neovascularisation despite panretinal photocoagulation

OBJECTIVES

To investigate the safety and effectiveness of pre-emptive vitrectomy in eyes with severe non-fibrotic proliferative diabetic retinopathy.

METHODS

A multi-centre, retrospective, observational study. Pre-emptive vitrectomy was performed in non-fibrotic diabetic eyes with a visual acuity (VA) of 20/50 or better, where there was extensive persistent neovascularisation despite prior panretinal photocoagulation, and where the fellow eye had established sight loss despite vitrectomy for tractional complications. The primary outcome measure was the VA at last visit.

RESULTS

Twenty patients were included. The mean age was 39 ± 14 years. Fifteen patients were Type 1 diabetic. The median baseline VA was 20/30 and remained stable at 20/28 at last visit (median follow-up period: 24 months). Eight eyes (40.0%) developed post-operative vitreous cavity haemorrhage; 4 of which required a vitreous cavity washout procedure. There were no post-operative retinal detachments. The index eye remained the significantly better eye at all time points bar one month post-surgery. Regression of retinopathy grading was observed in all eyes.

CONCLUSION

In this pilot study, we found no sight loss with pre-emptive diabetic vitrectomy. Better eye status was maintained in this high-risk group. Further study with larger number of patients and longer-term follow-up is indicated.

Long-term visual prognosis and characteristics of recurrent retinal detachment after silicone oil removal

PURPOSE

Silicone oil (SO) is commonly used for tamponade purposes in retinal detachment (RD) surgery, but the long-term visual prognosis after removal of the oil, and in particular, what is known about the recurrence of RD after SO removal, remains unclear. The purpose of this study is to evaluate the long-term vision prognosis after SO removal, and to understand the frequency and characteristics of RD recurrence.

METHODS

We retrospectively reviewed the medical charts of 1017 eyes of patients with a diagnosis of RD who had a pars plana vitrectomy with SO tamponade between January 2009 and December 2018. Best-corrected visual acuity (BCVA) was obatained before and after vitrectomy and also at the last visit. After SO removal, the group who showed improvement in visual acuity and the group who did not were compared. The anatomical results were compared between the group in which the retina was detached again after SO removal and the group in which the retina was not detached. To determine whether the duration of SO tamponade affects RD recurrence, further analysis was performed by dividing subgroups according to SO tamponade duration. RD recurrence, visual acuity, SO tamponade period were investigated.

RESULTS

Mean follow-up period was 56.65 ± 72.02 months. An average SO tamponade period was 6.68 ± 11.39 months. The average logMAR BCVA was 1.75 ± 0.91 before SO injection, 1.60 ± 0.75 before SO removal and 1.29 ± 0.96 after the removal. After SO removal, 926 of the 1017 (91.1%) patients had well attached retina without recurrence. There was no significant difference in visual acuity before SO removal in re-detachment group compared to no re-detachment group, but visual acuity of re-detachment group was worse than no re-detachment group after SO removal (p<0.001). The SO tamponade period in the group with improved vision after SO removal was 5.09 ± 9.87 months, and the period was significantly shorter than the 9.09 ± 13.05 months in the group not showing vision recovery (p = 0.005). The occurrence of corneal opacity was significantly higher in the group with SO over 6 months, than those of the two groups with SO tamponade duration of less than 3 months and between 3 and 6 months (p = 0.038). The longest tamponade group showed the worst final vision after SO removal (p<0.001).

CONCLUSION

The prognosis for final vision is generally good when performing surgery using SO in RD, but considering the complications that arise after surgery, long-term retention of SO is not recommended and the timing of SO removal should be considered.

Outcomes and Complications of Pars Plana Vitrectomy for Tractional Retinal Detachment in People With Diabetes: A Systematic Review and Meta-analysis

Importance

Tractional retinal detachment (TRD) occurs in approximately 5% of people with proliferative diabetic retinopathy and poses a threat to vision. Pars plana vitrectomy (PPV) is the treatment of choice for TRD.

Objective

To determine anatomic and functional outcomes of PPV for the treatment of TRD in people with diabetes (dTRD).

Data Sources

MEDLINE and Embase were searched systematically from January 1, 2000, to February 20, 2022. In addition, a reference list of eligible studies were screened.

Study Selection

Eligible studies were those published in English, those reporting outcomes of PPV for dTRD, and those that included more than 25 eyes and with a minimum follow-up of 3 months.

Data Extraction and Synthesis

Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines for data extraction/synthesis were followed, and the National Institute for Health quality assessment tool was used to assess risk of bias. Study eligibility was determined independently by 2 reviewers; data extraction was conducted by 1 reviewer and entries checked for accuracy by another. Data were pooled using a random-effects model.

Main Outcomes and Measures

Main outcomes included rate of failure of retinal reattachment following 1 surgery and final visual acuity (VA). The association of baseline patient characteristics and surgical maneuvers with postoperative surgical outcomes was investigated.

Results

Of the 406 studies identified, 38 (3839 eyes) were eligible and included for analysis. Patients had a median (IQR) age of 52.2 (49.6-55.7) years. In the studies reporting patient sex (31 of 38 studies), 1441 were female individuals (50.1%). The overall failure rate of retinal reattachment after 1 surgery was 5.9% (95% CI, 1.4%-8.3%), and the mean final VA was 0.94 (95% CI, 0.82-1.05) logMAR (approximate Snellen equivalent, 6/53; 95% CI, 6/39-6/71). People with higher preoperative VA achieved higher postoperative vision (0.66 logMAR worse final vision; 95% CI, 0.39-0.84 per 1.0 logMAR worse at baseline; P <.001). On multivariable analysis, no other patient characteristics or surgical variables had a statistically significant association with outcomes.

Conclusions and Relevance

Results of this systematic review and meta-analysis suggest that PPV was an effective strategy to achieve retinal reattachment in people with dTRD. Given that higher preoperative VA was the only factor associated with higher postoperative vision, early intervention should be considered and discussed in detail with patients. Overall, final postoperative VA remains low, and patients should be counseled on the guarded prognosis of dTRD.

Long-Term Outcomes of Same Patient Eyes Treated with Pars Plana Vitrectomy in One Eye and Conventional Treatment in the Other for Complications of Proliferative Diabetic Retinopathy

The purpose of this study was to evaluate the long-term, real-world outcomes of pars plana vitrectomy (PPV) for complications of proliferative diabetic retinopathy. A retrospective review involving 64 patients with proliferative diabetic retinopathy that underwent PPV in their worse-seeing eye were followed for a minimum of 8 years. The fellow eye underwent conventional treatment. Patients were divided into two groups by age: patients younger than 50 years of age and patients older than 50. In the younger than 50 group, 89% of vitrectomized eyes had improved visual acuity (VA) while 3.6% had decreased VA. A total of 14% of vitrectomized eyes required additional laser and 11% required reoperations. In the conventional treatment eyes, 25% had improved VA while 68% had decreased VA (p < 0.05). A total of 72% required additional laser and 60% required PPV. In the older than 50 group, 86% of vitrectomized eyes had VA improvement and 3% had decreased VA. A total of 8% required laser and 8% required reoperations. In the conventional treatment eyes, 30% improved VA and 48% had decreased VA (p < 0.05). Additional procedures required included laser in 70% and PPV in 17%. In both age groups, eyes that underwent PPV had better final visual outcomes than eyes that received conventional treatment for PDR.

Vitreous Substitutes as Drug Release Systems

Vitreous substitutes are traditionally used to stabilize the retina after vitrectomy. In recent years, various approaches have been developed for using the vitreous substitute not only as a tamponade but also as a drug release system to tackle ocular diseases. This review provides an overview of the requirements for vitreous substitutes and discusses the current clinically applied as well as novel polymer-based vitreous substitutes as drug delivery systems, including their release mechanisms, efficiencies, challenges, and future perspectives.

An update on the management of diabetic tractional retinal detachment

Background: Tractional retinal detachment (TRD) occurs when contractile forces in the vitreous and neovascular tissue lead to the detachment of the neurosensory retina. The pre-operative use of antivascular endothelial growth factor (anti-VEGF) and advances in microsurgical instrumentation, such as a small gauge vitrectomy (SGV), have improved surgical outcomes.Aim: The purpose of this review is to highlight recent trends in the management of diabetic TRD, supporting earlier surgical intervention and the expanded surgical indications.Methods: PubMed was searched for the following terms: ‘diabetes’ OR ‘diabetic retinopathy’ AND ‘TRD’ AND ‘pars plana vitrectomy (PPV)’ AND ‘anti-VEGF’ AND ‘endophotocoagulation’. Reference lists were reviewed for additional articles. The review was focused on all articles later than 2010 for recent updates on the ever-changing management of this disease entity. No case reports were included in this review article.Results: Management of TRD continues to remain challenging, despite the recent advancements in techniques and instrumentation. Each case needs to be individualised, with careful pre-operative planning, understanding of patient expectations and counselling, coupled with meticulous surgical skills and diligent postoperative management.Conclusion: Management of TRD continues to remain challenging despite recent advances in techniques and instrumentation. Vitrectomy for TRD can improve vision-related quality of life, and the continued evolution and improvement in surgical techniques and adjunctive pharmacotherapy will most likely continue to improve postoperative outcomes.Contribution: The paper presents an overview of current management of tractional retinal detachment in patients with advanced proliferative diabetic retinopathy. 

Clinical features and surgical outcomes of complications of proliferative diabetic retinopathy in young adults with type 1 diabetes mellitus versus type 2 diabetes mellitus - A comparative observational study

Purpose:

To evaluate the clinical profile, visual outcomes, and complications among young adult patients with type 1 diabetes mellitus (insulin-dependent DM-T1DM) in comparison with patients with type 2 diabetes mellitus (T2DM) undergoing vitrectomy for complications of proliferative diabetic retinopathy (PDR).

Methods:

A retrospective review of patients between 18 and 45 years with T1DM undergoing vitrectomy for complications of PDR between June 2017 and June 2019, with a minimum follow-up of 12 months. Consecutive patients between 30 and 45 years with type 2 diabetes (non-insulin-dependent DM-T2DM) who underwent vitrectomy for the same indications were retrospectively enrolled as the control group.

Results:

There were 42 eyes (28 patients) in the T1DM group and 58 eyes (47 patients) in the T2DM group. The average age at operation was 35.9 ± 6.88 years and 39.8 ± 3.03 years, respectively (P < 0.001). At the end of follow-up, the mean logarithm of the minimum angle of resolution (logMAR) best-corrected visual acuity (BCVA) improved from 1.53 ± 0.55 to 1.30 ± 0.93 (P value 0.07) in the T1DM group and from 1.59 ± 0.46 to 1.00 ± 0.78 in the T2DM group (P = 0.0001). The rate of the primary and final reattachment was 76.2% and 88.1% in the T1DM group and 84.5% and 96.6% in the T2DM group. Preoperative macular tractional retinal detachment (MTRD) and neovascular glaucoma (NVG) in both the groups, chronic kidney disease (CKD) and lack of preoperative Pan retinal photocoagulation (PRP) in the T1DM group, hypertension (HTN) and, resurgery in the T2DM group, were risk factors for poor vision at the final follow-up.

Conclusion:

The visual and anatomic outcomes were poorer in the T1DM patients which could be due to the longer duration of diabetes with worse glycemic control, associated comorbidities like CKD, and a higher incidence of MTRD.

Management of Complications and Vision Loss from Proliferative Diabetic Retinopathy

PURPOSE OF REVIEW

Diabetes can be associated with profound visual loss due to several mechanisms. As the duration of diabetes and blood glucose levels increase, these changes become more severe. The proliferation of new blood vessels, vitreous hemorrhage, and tractional retinal detachments may ultimately result and can be devastating to visual function. New advances, including anti-vascular endothelial growth factor (VEGF) medications and innovative microsurgical instruments, have provided additional methods for the management of diabetic retinopathy in the clinic and in the operating room, leading to improved outcomes.

RECENT FINDINGS

Advances in earlier treatment of proliferative diabetic retinopathy, especially with anti-VEGF injections, allow for a reduction in severity, improved vision, and more controlled and successful surgery. Modern surgical techniques and instrumentation have also allowed for improved patient outcomes. Future research into sustained delivery and release of anti-VEGF, reducing the need for frequent in-office injections, may prove to be additionally beneficial. Over the last decade, anti-VEGF has become an increasingly common treatment modality for the management of proliferative diabetic retinopathy, vitreous hemorrhages, and tractional retinal detachments. Further research is needed to determine the ideal method of delivery and timing of the treatment.

WIDE-FIELD SWEPT-SOURCE OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY OF DIABETIC TRACTIONAL RETINAL DETACHMENTS BEFORE AND AFTER SURGICAL REPAIR

PURPOSE

Wide-field (WF) swept-source (SS) optical coherence tomography angiography (SS-OCTA) was used to image diabetic tractional retinal detachments (TRDs) before and after pars plana vitrectomy. The clinical utility of SS-OCTA was assessed.

METHODS

Patients with diabetic TRDs were imaged prospectively with SS-OCTA. Ultrawide-field imaging was obtained when possible. Postoperative WF SS-OCTA imaging was performed.

RESULTS

From January 2018 through December 2019, 31 eyes of 21 patients with diabetic TRDs were imaged. Wide-field SS-OCTA en-face images captured all areas of TRD and fibrovascular proliferation within the posterior pole that were visualized on ultrawide-field imaging. Optical coherence tomography angiography B-scans revealed the vascularity of preretinal membranes and identified areas of vitreoretinal traction and posterior vitreous detachment. Ten eyes underwent pars plana vitrectomy. Postoperative SS-OCTA imaging demonstrated removal of fibrovascular membranes, relief of traction, and resolution of TRDs. Retinal ischemia before and after surgical repair appeared similar.

CONCLUSION

All clinically relevant features of diabetic TRDs were identified at baseline and assessed longitudinally after pars plana vitrectomy using WF SS-OCTA, which showed resolution of vitreoretinal traction and no apparent change in the status of retinal perfusion after surgery. If the media are clear and fixation is adequate, WF SS-OCTA is likely the only imaging modality needed for the diagnosis and longitudinal evaluation of diabetic TRDs.

Substitutes and Colloidal System for Vitreous Replacement and Drug Delivery: Recent Progress and Future Prospective

Vitreoretinal surgeries for ocular diseases such as complicated retinal detachment, diabetic retinopathy, macular holes and ocular trauma has led to the development of various tamponades over the years in search for an ideal vitreous substitute. Current clinically used tamponade agents such as air, perfluorocarbons, silicone oil and expansile gases serve only as a short-term solution and harbors various disadvantages. However, an ideal long-term substitute is yet to be discovered and recent research emphasizes on the potential of polymeric hydrogels as an ideal vitreous substitute. This review highlights the recent progress in the field of vitreous substitution. Suitability and adverse effects of various tamponade agents in present day clinical use and biomaterials in the experimental phase have been outlined and discussed. In addition, we introduced the anatomy and functions of the native vitreous body and the pathological conditions which require vitreous replacement.

Retinopathy of prematurity and neonatal gut microbiome: An interview with Professor Dimitra Skondra, Associate Professor of Ophthalmology and Vitreoretinal Surgeon at The University of Chicago (USA)

Retinopathy of prematurity (ROP) is a sight-threatening disorder of the retina affecting neonates of very low birth weight and gestational age, and is characterized by the development of abnormal blood vessel growth. According to Dr Dimitra Skondra, Associate Professor of Ophthalmology and Vitreoretinal Surgeon at the University of Chicago School of Medicine in Chicago, USA, the neonatal gut microbiome may be implicated in the neoangiogenesis process in the neonatal retina and this role may be one of the missing links in the pathogenesis of ROP. The human gut microbiome consists of bacteria, viruses, protozoa and fungi, which colonize the sterile fetal intestine, and differ depending on gestational age, mode of delivery, type of neonatal feeding, the usage of antibiotics and the requirement of neonatal intensive care. To date, it has been related to multiple nutritive, metabolic and immunological functions and has been implicated in the pathogenesis of several human diseases, such as the inflammatory bowel diseases, autoimmune and neurogenerative disorders, metabolic syndrome, cardiovascular diseases and various types of malignant neoplasias. Recent research has proposed that the neonatal gut microbiome profile in high-risk neonates who develop ROP is significantly enriched with Enterobacteriacaea species several weeks prior to the diagnosis of ROP. Further research using animal models is required to prove the causative or secondary role of the microbiome composition in the development and clinical course of ROP. If this role is proven, the gut microbiome could then be a target of intervention for personalized medicine in the prevention and therapeutic management of ROP in neonates.

Survival Time of Visual Gains after Diabetic Vitrectomy and Its Relationship with Ischemic Heart Disease

Vitrectomy surgery in proliferative diabetic retinopathy improves the vision-related quality of life. However, there is lack of data on the duration of maintenance of visual gains post vitrectomy. This study thus aimed to determine the survival time of visual gains and the prognostic factors of vision loss after vitrectomy surgery for complications of proliferative diabetic retinopathy. A retrospective cohort study was conducted in an ophthalmology clinic in Malaysia. We included 134 patients with type 2 diabetes mellitus on follow-up after vitrectomy for proliferative diabetic retinopathy. Visual acuity was measured using the log of minimum angle of resolution (LogMar). A gain of ≥0.3 LogMar sustained on two subsequent visits was considered evidence of visual improvement post vitrectomy. Subjects were considered to have vision loss when their post-operative visual acuity subsequently dropped by ≥0.3 LogMar. Kaplan–Meier analysis was used to determine the survival time of visual gains. Cox Proportional Hazard regression was used to determine the prognostic factors of vision loss. The median age of patients was 56.00 years (IQR ± 10.00). The median duration of diabetes mellitus was 14.00 years (IQR ± 10.00). Approximately 50% of patients with initial improvement post vitrectomy subsequently experienced vision loss. The survival time, i.e., the median time from surgery until the number of patients with vision loss formed half of the original cohort, was 14.63 months (95% CI: 9.95, 19.32). Ischemic heart disease was a significant prognostic factor of vision loss. Patients with underlying ischemic heart disease (adjusted HR: 1.97, 95% CI: 1.18, 3.33) had a higher risk of vision loss post vitrectomy, after adjusting for other factors. Approximately half the patients with initial visual gains post vitrectomy maintained their vision for at least one year. Ischemic heart disease was a poor prognostic factor for preservation of visual gains post vitrectomy.