Predictors and Outcomes of Vitrectomy and Silicone Oil Injection in Advanced Diabetic Retinopathy

Incidental Finding of Suprachoroidal Space's Silicone Oil Migration: A Tumor-Mimicking Lesion and Its Clinical Management

The migration of silicone oil into the suprachoroidal region is a rare complication of vitrectomy. A 70-year-old man was admitted to our ocular oncology unit with a choroidal elevation in the nasal area, as well as signs of pars plana vitrectomy surgery performed about 5 years ago for retinal detachment. The patient underwent ocular ultrasound, visual field test, fluorangiography, and magnetic resonance imaging, which led to the diagnosis of silicone oil migration in the suprachoroidal space. Silicone oil may move into the suprachoroidal area, mimicking choroidal neoformation. It is important to have a comprehensive diagnosis and then set up the appropriate treatment. [Ophthalmic Surg Lasers Imaging Retina 2024;55:104-108.].

Comparison of residual silicone oil index after removal of silicone oil with fluid-air versus oil-fluid exchange

Objectives

To compare the effectiveness of fluid-air exchange with silicone oil-fluid exchange in reducing the residual silicone oil (SO) droplets after the removal of SO.

Methods

This was a prospective, quasi-experimental study conducted from October 2021 to February 2022 at Eye Unit-III, COAVS, Mayo Hospital, Lahore. Sixty-one patients with siliconized eyes underwent removal of SO with two different techniques and were divided into fluid-air exchange and oil-fluid exchange groups. To quantify the residual silicone droplets objectively, B-scan echographic images were analyzed within seven days of surgery. Silicone oil index (SOI) which is the amount of residual SO droplets/vitreal area in the images was calculated with the help of imagej software.

Results

The residual SOI of the fluid-air exchange group (0.99 ± 1.76%) was significantly lower than the oil-fluid exchange group (3.25 ± 3.85%). The SOI is positively correlated with the duration of tamponade, preoperative intraocular- pressure and axial length. Persistent IOP elevation post-operatively was seen in 16.67% individuals in the fluid-air exchange group and 54.8% individuals in the oil-fluid exchange group.

Conclusion

Fluid-air exchange group was found to be superior in reducing residual SO droplets than the oil-fluid exchange group.

Factors influencing compliance in RRD patients with the face-down position via grounded theory approach

Patients with rhegmatogenous retinal detachment (RRD) require face-down positioning (FDP) for 3-6 months or longer after pars plana vitrectomy (PPV) combined with silicone oil (SO) tamponade. This paper aimed to identify the factors that influenced FDP compliance. This study adopted semi-structured interviews with patients who require FDP after SO tamponade. Constructivist grounded theory was utilized in this study. The qualitative data was analyzed and coded via NVivo 11.0 through open coding, axial coding and selective coding. Twenty-four RRD patients were involved. The interviews yielded five main themes that defined home FDP compliance were identified: posture discomfort, doctor-patient communication, psychological factors, occupational character, and family factors. A theoretical model of the influencing factors of postural compliance of FDP was constructed based on the interview analysis. A variety of factors can affect FDP conformity. We can increase compliance of RRD patients by enhancing comfort, encouraging doctor-patient communication, providing comprehensive care, promoting community-based intervention, and strengthening family education.

Intravitreal recombinant tPA before vitrectomy for diabetic tractional retinal detachment: A randomized controlled trial

PURPOSE

To investigate the effect of intravitreal recombinant tissue plasminogen activator (rt-PA) injection before vitrectomy on surgical facility and outcome in diabetic tractional retinal detachments (TRD).

METHODS

Prospective, randomized, interventional clinical trial. A total of 38 eyes with diabetic TRD were candidates for vitrectomy. Patients were randomized 1:1 to receive intravitreal rt-PA, five to seven days before vitrectomy or no injection. Intraoperative surgical facility and anatomic success at month 3 after surgery were assessed.

RESULTS

Mean patient age was 54.2 ± 9.4 years. There was no statistically significant difference between rt-PA and no injection groups with regard to anatomic success (89% versus 95%, respectively, P = 0.547) and best corrected visual acuity at 3 months (2.0 versus 2.1 logMAR, respectively, P = 0.840). However, surgical facility score was statistically significantly lower in rt-PA injection group compared to no injection group (4.1 ± 1.7, 5.8 ± 2.0, respectively, P = 0.007).

CONCLUSIONS

Vitrectomy for TRD was easier after preoperative rt-PA injection, without affecting the anatomic and visual outcomes.

Characteristics, fates and complications of long-term silicone oil tamponade after pars plana vitrectomy

BACKGROUND

Silicone oil tamponade has become a mainstay in treatment of advanced retinal detachment due to multiple etiologies. The aim of this study is to assess the characteristics, fates and complications of long-term silicone oil tamponade after par plana vitrectomy (PPV), and to compare the outcomes of different silicone oil viscosities used in a cohort of consecutive patients.

METHODS

This is a retrospective comparative case series of eyes undergoing vitrectomy with silicone oil tamponade for retinal detachment by a single surgeon using different oil viscosities that were followed for one year with the silicone oil in situ. Visual acuity (VA), intraocular pressure (IOP) and complications associated with the follow up period were analyzed and compared.

RESULTS

Eighty-five eyes of 85 patients were included in this study. Forty three patients had 1000 centistoke (cs) oil injected and 42 patients had 5000cs oil utilized. Demographic, cause of retinal detachment and preoperative ocular characteristics were similar in both groups. Long term complications in both groups included ocular hypertension (67.4% vs 66.7%), keratopathy due to silicone oil emulsification and migration to the anterior chamber (7.0% vs 11.9%), recurrent retinal detachment (4.7% vs 19%) and epiretinal membrane formation (7% vs 19%). In the 1000cs oil group, there was no significant difference between baseline IOP and any subsequent visit. There was a significant difference between baseline IOP and visits at day 1 (with IOP difference of 2.61 mmHg (±6.5)) (p = 0.028), 1 month (with IOP difference of 3.52 mmHg (±8.1)) (p = 0.026), 4 months (with IOP difference of 6.38 mmHg (±9.3)) (p = 0.005), and one year (with IOP difference of 4.24 mmHg (±11.1)) (p = 0.048), all higher in the post-operative period in the 5000cs oil group. Excluding the first post-operative day, no significant difference was found for VA between baseline visits and subsequent visits for either silicone oil groups.

CONCLUSION

In this cohort of patients with long-term silicone oil tamponade after PPV to treat retinal detachment, IOP increased significantly in patients who received 5000cs silicone oil. There was no significant difference between other complication rates in patients receiving either oil viscosities. Long term silicone oil tamponade remains a viable option in certain cases, and a vigilant follow up for complications is necessary to limit any adverse effects and improve visual and surgical outcomes.

Pars Plana Vitrectomy Reoperations for Complications of Proliferative Diabetic Retinopathy

Objective

To report visual acuity in patients undergoing pars plana vitrectomy (PPV) reoperations for complications of proliferative diabetic retinopathy (PDR).

Design

Retrospective case series.

Subjects

Diabetic patients undergoing reoperation with PPV between 2015 and 2018 at a university referral center.

Methods

Patient charts were reviewed for indication for initial and repeat PPV, baseline clinical characteristics including gender, age, and lens status, and pre- and post-operative best-corrected visual acuity.

Main Outcome Measures

Best-corrected visual acuity at last follow-up.

Results

Of 538 eyes (409 patients) undergoing a PPV for diabetic retinopathy, 153 (28.4%) eyes had reoperation. Among the 130 eyes (119 patients) that met the inclusion criteria, 55 eyes (50 patients) underwent reoperation for complications of PDR, defined as non-clearing vitreous hemorrhage (NCVH) and/or tractional retinal detachment (TRD). Within this subgroup of 55 eyes, 19 (34.5%) eyes had an indication for the first surgery of NCVH. Fourteen (73.7%) of these NCVH eyes achieved a visual acuity of 20/80 or better. When the indication for the first surgery was TRD (33 eyes, 60%), 8 (24.2%) eyes achieved this same outcome (p=0.0011).

Conclusion

Approximately one of every four eyes treated with PPV for PDR will undergo repeat PPV during follow-up. VA outcomes after the repeat PPV were variable, with NCVH cases achieving better outcomes compared to TRD.

Recurrent retinal detachment after diabetic vitrectomy

PURPOSE

To investigate the characteristics of recurrent retinal detachment (RD) after diabetic vitrectomy (DV).

METHODS

Consecutive cases underwent vitrectomy for recurrent RD after DV was collected and separated into the following four groups for analysis: rhegmatogenous RD (RRD), pure tractional RD (Proliferative Subgroup 1), combined RD with proliferative tissue within the equator (Proliferative Subgroup 2), and combined RD with both posterior and peripheral proliferations (Proliferative Subgroup 3).

RESULTS

Of the 41 cases enrolled, retinal reattachment was achieved in 73.2%. Over all, visual acuity was statistically better after operation (p = 0.001). All cases in the RRD group (four cases) had reattachment and a better final vision (p = 0.008). In the proliferative subgroups, those with pure tractional RD (Subgroup 1, seven cases) had the best visual acuity at the time of recurrent RD (p = 0.002). Subgroups 2 and 3 showed statistically significant better final visual acuity (p = 0.045 and 0.019, respectively). Poor preoperative vision (p = 0.001), non-attachment (p = 0.004), and neovascular glaucoma (p = 0.001) were associated with poor prognosis.

CONCLUSIONS

Visual acuity may improve after operation for recurrent RD after diabetic vitrectomy. Visual prognosis was better in cases with pure RRD. In the proliferative subgroups, vision was impaired by the development of neovascular glaucoma and retinal non-attachment.

Evaluation of Retinal Detachment After Diabetic Vitrectomy: Causes and Ways of Management

Purpose

To assess the causes and the ways of management of rhegmatogenous retinal detachment (RRD) after pars plana vitrectomy (PPV) performed in diabetic patients with advanced diabetic eye disease.

Methods

Retrospective review of the records of the patients who had undergone PPV for complicated proliferative diabetic retinopathy (PDR) was done. Cases with RRD after the PPV were analyzed in the study (n = 32). Preoperative, operative, and postoperative data of the patients were recorded. All patients were recruited for a final follow-up visit.

Results

This retrospective case-control study included 400 eyes of 345 patients. Prolonged surgical duration increased the risk of developing RRD (odds ratio = 1.6342, p = 0.0321). The presence of intraoperative retinal breaks increased the risk of developing postoperative RRD (odds ratio = 2.2308, p = 0.0380). Also, complex diabetic detachment that needed for bimanual dissection of the membranes during surgery were associated with a higher risk of developing postoperative RRD (odds ratio = 2.7311, p = 0.0401).

Conclusion

Rhegmatogenous retinal detachment following diabetic vitrectomy needs a further vitrectomy for the management and usually has poor visual outcome. Prolonged surgical duration, the presence of intraoperative retinal breaks, and the need for bimanual dissection of the membranes (major complex cases) during surgery were associated with higher risk of developing RRD postoperatively.

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.

Silicone oil removal: post-operative complications

PURPOSE

To describe the characteristics, outcomes and complications of eyes after silicone oil removal.

METHODS

Retrospective case series of eyes that underwent oil removal between 2012 and 2016 at The Institute of Ophthalmology and Visual Science. Visual acuity (VA), intraocular pressure (IOP) and rates of retinal re-detachment, hypotony, ocular hypertension, corneal decompensation, cystoid macular edema (CME) and cataract progression were evaluated.

RESULTS

Totally, 101 eyes of 99 patients (65% male, average age 47.2 years) were identified. Oil tamponade had been used for retinal detachment (RD) repair in all eyes; 15 eyes had also undergone an open globe repair previously. The most common vitreous substitutes used after oil removal were balanced salt solution (BSS) and air in 90% of eyes. The average time of oil tamponade before removal was 9.46 months. The average logMAR VA before oil removal was 1.7 which improved to an average of 1.4 post-operatively. The average IOP pre-operatively was 16.1 mm Hg, which decreased to an average of 14.8 mm Hg post-operatively. Complications after oil removal, included retinal re-detachment (6.9%), hypotony (7.9%), ocular hypertension (12.9%), corneal decompensation (9.9%), CME (2%) and cataract progression (68%).

CONCLUSION

This study showed an overall improvement in VA and decrease in IOP after oil removal. Cataract progression was the most common complication.

Beneficial visual outcome of vitrectomy and delamination surgery for tractional complications of diabetic retinopathy in a cohort of black patients

BACKGROUND/AIMS

Poor visual outcomes have recently been reported in black patients undergoing vitrectomy and delamination surgery for complications of proliferative diabetic retinopathy. We therefore investigated the outcome of surgery on a similar cohort of black patients and examined for potential predictors of visual success.

METHODS

A single-centre retrospective case review of consecutive black patients who underwent vitrectomy and delamination surgery for complications of PDR between July 2010 and September 2017. The primary outcome measure was change in visual acuity (VA) at 6 months post-operatively. Multiple linear regression analysis was performed to evaluate determinants of change in VA.

RESULTS

A total of 44 eyes of 44 patients were included. Mean age was 53.7 (range: 24.3-75.8) years. In all, 43% were male. A total of 52% had adjunctive pre-operative anti-VEGF therapy. Mean pre-operative VA was 1.49 logMAR ± 0.73 (range 0.18 to 2.6 logMAR). Mean change in VA at 6 months was a gain of 0.59 ± 0.94 logMAR (range 1.9 logMAR acuity loss to 2.5 logMAR acuity gain). Four cases required further surgery to treat rhegmatogenous detachment. The acuity of 68% improved by 0.3 or more logMAR. Silicone oil was used as primary tamponade in 7%. Pre-operative VA and use of silicone oil significantly predicted VA decline at 6 months (p = 0.001 and p = 0.007).

CONCLUSIONS

The majority of our cohort derived visual benefit from vitrectomy and delamination for PDR-related complications. Improvement in VA was comparable to outcomes from the UK National Ophthalmic Database report. Silicone oil should be avoided these patients if possible.

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.

Characteristics and Outcomes of Pars Plana Vitrectomy for Proliferative Diabetic Retinopathy Patients in a Limited Resource Tertiary Center over an Eight-Year Period

Purpose

To report characteristics and visual results in patients with PDR-associated complications following pars plana vitrectomy (PPV) in a tertiary center over an eight-year period.

Methods

Medical records of diabetic retinopathy patients receiving PPV between January 2007 and December 2014 for PDR-related complications were reviewed.

Results

A total of 890 consecutive PDR patients were included in the study. PPVs were performed for tractional retinal detachment (36.6%), persistent vitreous hemorrhage (VH) (35.4%), combined tractional and rhegmatogenous retinal detachment (14.5%), and vitreoretinal abnormalities (13.5%), respectively. Preoperative intravitreal bevacizumab injection (IVB) within two weeks prior to PPV and 23G vitrectomy systems was found to decrease the risk for intraoperative retinal break development (P=0.045 and P=0.015, respectively). The incidence of early dense postoperative VH decreased significantly with the administration of preoperative or intraoperative IVB at the end of PPV. Postoperative visual results significantly correlated with the initial visual acuity level, intraoperative retinal break development, and retained silicone oil tamponade at the final visit (P < 0.001, P=0.040, and P=0.044, respectively). Administration of adjuvant IVB either before or at the end of PPV had no significant association with the final visual outcomes.

Conclusions

This study reported an improvement in visual acuity in nearly half of patients receiving PPV for PDR-associated complications in a limited resource center. The incidence of intraoperative retinal break and early postoperative VH decreased significantly with the application of IVB injections. Poor final visual outcomes were related to the lower initial visual acuity levels, intraoperative retinal breaks, and postoperative retained silicone oil.