Vitreous rebleed following sutureless vitrectomy: Incidence and risk factors

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.

Late postoperative vitreous cavity hemorrhage after vitrectomy for proliferative diabetic retinopathy-observation versus intervention

PURPOSE

To analyze the outcome of intervention versus observation for vitreous cavity hemorrhage occurring after a 2-month period of blood-free cavity (late postoperative vitreous cavity hemorrhage-POVCH) in eyes operated by vitrectomy for complications of proliferative diabetic retinopathy (PDR).

METHODS

This study was a 10-year retrospective, observational, multi-center study involving eight major vitreoretinal surgical centers across India from January 2010 to December 2019. The primary objective of the study was to assess the visual and clinical outcomes of various management approaches for late POVCH. The key secondary objective was to determine the best management option that prevented recurrence. Patients with follow-up of less than 6 months of POVCH management were excluded.

RESULTS

The occurrence of late POVCH was studied in 261 eyes. The median time to occurrence was 7 months (range: 2-87) postvitrectomy/silicone oil removal. The majority (58%) experienced a single, nonrecurring POVCH event. Visual acuity outcome was independent of all management approaches (P = 0.179; mean follow-up 20.7 ± 14.1 months). With watchful observation, spontaneous resolution was noted in 83% (60/72 eyes) of eyes in 81.5 days (interquartile range, 169.75). Silicone oil injection was most effective in preventing recurrence (P < 0.001).

CONCLUSION

The current treatment practice of late POVCH management in PDR suggests that watchful observation for at least 3 months could be as efficacious as any surgical intervention.

Perioperative systemic blood pressure parameters and clinical outcomes following 27g vitrectomy for diabetic tractional detachment repair

Background

Extremes in perioperative blood pressures are known risk factors for adverse outcomes after surgical interventions. There is scarce literature studying these parameters as predictors of outcomes after ocular surgery.

Methods

This was a retrospective single-centre interventional cohort analysis to evaluate the relationship between perioperative (preoperative and intraoperative) blood pressure value and variability and postoperative visual and anatomic outcomes. Included were patients who underwent primary 27-gauge (27g) vitrectomy for repair of diabetic tractional retinal detachment (DM-TRD) with at least 6 months of follow-up. Univariate analyses were conducted via independent two-sided t-tests and Pearson’s χ2tests. Multivariate analyses were conducted via generalised estimating equations.

Results

71 eyes of 57 patients were included in the study. Higher preprocedure mean arterial pressure (MAP) was associated with fewer Snellen lines of improvement at postoperative month 6 (POM6) (p<0.01). Higher mean intraoperative systolic blood pressure (SBP), diastolic blood pressure and MAP were associated with visual acuity 20/200 or worse at POM6 (p<0.05). Patients with sustained intraoperative hypertension had 1.77 times the risk of visual acuity 20/200 or worse at POM6 compared with those without sustained intraoperative hypertension (p=0.006). Higher SBP variability was associated with worse visual outcomes at POM6 (p<0.05). Blood pressure was not associated with macular detachment at POM6 (p>0.10).

Conclusions

Higher average perioperative blood pressure and blood pressure variability are associated with worse visual outcomes in patients undergoing 27g vitrectomy for DM-TRD repair. Patients with sustained intraoperative hypertension were approximately twice as likely to have visual acuity 20/200 or worse at POM6 compared to those without sustained intraoperative hypertension.

Same-Day Cancellation is Higher in Outpatient Pars Plana Vitrectomy for Proliferative Diabetic Retinopathy

Purpose

Safety and efficiency of ambulatory pars plana vitrectomy (PPV) for proliferative diabetic retinopathy (PDR) patients is worthy of attention, since patients always have severe systemic diseases. The purpose of this study was to compare the incidence of same-day cancellation of PPV for PDR between outpatients and inpatients and to analyze the causes of cancellations.

Patients and Methods

This is a retrospective review of consecutive PPV procedures for PDR from January 2019 to April 2021 at either the ambulatory or the inpatient surgery center in an academic tertiary referral center. Data on patient surgery plan, same-day surgical cancellation and follow-up were recorded. Differences in cancellation rate and reasons for cancellation (e.g. medical factors, patient reasons and administrative problems) between outpatients and inpatients were compared.

Results

In total, 1810 consecutive PPV procedures of 1367 patients were identified; 1509 (83.4%) were managed as inpatient surgeries and 301 (16.6%) as outpatient surgeries. The total same-day cancellation rate was 5.2% for all patients. Although outpatients were younger (51 years vs 52 years, P < 0.001), had less proportion of hypertension (60.5% vs 74.0%), coronary artery disease (10.0% vs 18.8%), renal insufficiency (9.3% vs 18.0%) and cerebrovascular diseases (1.0% vs 11.4%) (all P < 0.001), had less proportion of patients with ASA III status (14.9% vs 27.4%, P < 0.001), and had higher proportion of regional anesthesia with MAC (19.9% vs 5.0%, P < 0.001), the cancellation proportion was significantly higher for outpatients than inpatients (12.3% vs 3.8%, P < 0.001). Overall, the most common reason for surgical cancellation was medical factors, occurring more frequently in outpatients than inpatients (91.9% vs 68.4%, P = 0.012).

Conclusion

Same-day cancellation is higher in outpatient pars plana vitrectomy for proliferative diabetic retinopathy. To reduce ambulatory surgery cancellations, it is important to strengthen the monitoring of preoperative systemic comorbidities and adjust medication if necessary.

Multiple factors in the prediction of risk of recurrent vitreous haemorrhage after sutureless vitrectomy for non-clearing vitreous haemorrhage in patients with diabetic retinopathy

Background

We aimed to analyse multiple factors in the prediction of risk of postoperative recurrent vitreous haemorrhage (RVH) for non-clearing vitreous haemorrhage in patients with diabetic retinopathy (DR) who underwent sutureless vitrectomy with 23- (23G) or 25-gauge (25G) narrow-gauge systems.

Methods

A retrospective consecutive case series design was used. DR patients who underwent sutureless vitrectomy for non-clearing vitreous haemorrhage between June 2017 and October 2019 were enrolled. All operations were performed at a tertiary hospital. Patient demographics and risk factors, including age, gender, duration of diabetes, preoperative fasting blood sugar levels (FBSL), systolic blood pressure (SBP), serum creatinine (Cr), urea, triamcinolone acetonide (TA), electrical coagulation, air-fluid exchange, pan-retinal photocoagulation status (PRP), anti-vascular endothelial growth factor drug (anti-VEGF), and other factors, were recorded. Patients were divided into two groups based on the timing of their postoperative RVH: immediate postoperative RVH (within 2 weeks after operation) and delayed postoperative RVH (beyond 2 weeks after operation).

Results

Overall, 167 eyes (167patients) were enrolled. Seventy eyes were underwent 23G and 25G sutureless vitrectomy performed in 97 eyes, respectively. Postoperative RVH developed in 18 eyes (25.7%) in Group 23G and in 20 eyes (21.6%) in Group 25G (P = 0.540). Of these, 3 eyes (4.3%) had severed RVH in Group 23G compared with 5 eyes (5.2%) in Group 25G (P = 0.584). Delayed postoperative RVH occurred in 6 eyes (8.6%) in Group 23G and 8 eyes (8.2%) in Group 25G (P = 0.789). A binomial logistic regression analysis revealed that age, duration of diabetes, and Cr level were significantly associated with RVH in both Group 23G (P < 0.05) and Group 25G (P < 0.05).

Conclusions

The incidence and severity of RVH were 25.7 and 4.3%, respectively, in Group 23G and 21.6 and 5.2%, respectively, in Group 25G. Thus, the 23G sutureless vitrectomy approach was as safe as the 25G sutureless vitrectomy approach for treating vitreous haemorrhage in patients with DR. A younger age, shorter duration of diabetes, and higher Cr levels were risk factors for postoperative RVH in sutureless vitrectomy.

Intravitreal ranibizumab injection at the end of vitrectomy for diabetic vitreous hemorrhage (Observational Study)

To evaluate the outcomes and complications of intravitreal injections of ranibizumab in patients during pars plana vitrectomy for treatment of diabetic vitreous hemorrhage. This retrospective, observational, comparative study included 103 patients (103 eyes) who underwent pars plana vitrectomy for treatment of diabetic vitreous hemorrhage. Sixty-six patients received an intravitreal injection of 0.05 mg (0.05 cc) of ranibizumab at the end of surgery. Main outcome measures were the occurrence of recurrent early vitreous hemorrhage, reoperation, intraocular pressure, best corrected visual acuity. Mean follow-up time was 6 months. The rate of rebleeding in the intravitreal ranibizumab (IVR) group was 6.1% (4 eyes), which is significantly lower than the control group (24.3%, 9 eyes, P < .01). The incidence of postoperative diabetic vitreous hemorrhage (PDVH) was significantly lower in the IVR group than the control group, OR=0.26, 95% CI= (0.06, 0.95). Visual acuity 6 months after operation was better in IVR group (P<.01) There was no difference in mean intraocular pressure between the 2 groups (P=.56). The present clinical study suggests that intravitreal injection of ranibizumab is effective in the prevention of postoperative diabetic vitreous hemorrhage in eyes undergoing pars plana vitrectomy for the treatment of diabetic vitreous hemorrhage.