Clinical Characteristics and Surgical Outcomes of Patients Undergoing Pars Plana Vitrectomy for Proliferative Diabetic Retinopathy

OBJECTIVE

To evaluate clinical characteristics impacting surgical outcomes of patients undergoing pars plana vitrectomy (PPV) for complications of proliferative diabetic retinopathy (PDR).

DESIGN

Retrospective consecutive observational case series of patients at a large county hospital in Dallas, Texas, from 2014 to 2019.

SUBJECTS

Seven hundred thirty-two patients (933 eyes) undergoing PPV for PDR complications.

METHODS

Collected data included demographics, surgical indication, adjuvant therapies, intraoperative course, complications, and best corrected visual acuity (BCVA). Patients with < 6 months of follow-up were excluded. Best corrected visual acuity was converted to logarithm of the minimum angle of resolution for analysis. Statistics performed included t test, analysis of variance, and multivariate analyses.

MAIN OUTCOME MEASURES

Postoperative BCVA, primary anatomic success rate, and postoperative complications.

RESULTS

Three hundred ninety-three patients were male (509 eyes; 54.5%) with an average age of 52 years. Postoperative BCVA at 6 months was significantly different among surgical indications: 0.79 versus 0.77 versus 1.20 (P < 0.0001) for vitreous hemorrhage (VH), vitreomacular interface abnormalities, and tractional retinal detachment (TRD), respectively. Adjuvant preoperative therapy with panretinal photocoagulation (PRP) versus no PRP (0.95 vs. 1.25; P < 0.001) and insulin versus no insulin (0.99 vs. 1.17; P < 0.01) were associated with improved vision. Iatrogenic breaks were associated with decreased postoperative vision (1.40 vs. 0.88; P < 0.001). The primary anatomic success rate for TRD was 85% (495 eyes). Combined TRD/RRD (tractional and rhegmatogenous retinal detachment) was associated with a lower success rate compared with macula-on/macula-off TRD, with odds ratios of 0.36, 0.46, and 0.53, respectively. Patients experiencing recurrent detachment postsurgery had worse preoperative visual acuity (VA) (1.93 vs. 1.63; P < 0.01) and were younger (47.6 vs. 50.0; P = 0.02). Postoperative complications occurred in 699 eyes (75%), with VH (498 eyes, 53%), cataract (465, 50%), and elevated intraocular pressure (149, 16%) being the most common. Two hundred thirty-six eyes (25%) required a second PPV operation. Endophthalmitis (1 eye; <1%) and choroidal detachment (5 eyes; <1%) were rare.

CONCLUSIONS

In this retrospective series analyzing surgical outcomes among patients with complications from PDR, vitrectomy led to improved vision on average, with a meaningful proportion of patients receiving additional surgical intervention. Surgical indication, presenting VA, age, and adjuvant therapies appeared to impact outcomes.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Unusual presentation of tractional retinal detachment in beta thalassemia minor

Purpose

To report a case of proliferative retinopathy with tractional retinal detachment associated with beta thalassemia minor in a 27-year-old female.

Observations

A young lady having beta thalassemia minor presented with decreased vision in both eyes, the effect being more severe in her right eye. The patient's other systemic history, including ophthalmic history, was unremarkable. The fundus examination revealed peripheral retinal ischemia in both eyes and tractional retinal detachment in the right eye.

Conclusion

Beta thalassemia minor is not associated with striking retinal pathology, nevertheless proliferative retinopathy. However, in this case the patient developed tractional retinal detachment that required surgery. This indicates that proliferative changes may develop in patients with beta thalassemia, and routine fundus examinations could be recommended for these patients.

Endoscopy-assisted pars plana vitrectomy in retinal detachments associated with anterior proliferative vitreoretinopathy and epiciliary membranes

BACKGROUND

Proliferative vitreoretinopathy (PVR) is the leading cause of recurrent retinal detachment. Anterior PVR can contribute to recurrent retinal detachment and is often difficult to remove during conventional pars plana vitrectomy. The purpose of this study is to report surgical outcomes of single endoscopy-assisted pars plana vitrectomy (E-PPV) in patients with tractional retinal detachments associated with anterior proliferative vitreoretinopathy and epiciliary membranes.

METHODS

Retrospective review of E-PPV between 2017 and 2021 at a tertiary referral center. Inclusion criteria involved adult patients who underwent E-PPV for tractional retinal detachment with anterior PVR and epiciliary membranes. Data collection included patients' demographics, ophthalmic exam findings, and surgical outcomes. A series of independent sample tests of proportion were conducted using a p-value of 0.05 as the threshold for statistical significance.

RESULTS

Eighteen out of 55 patients who underwent E-PPV met the inclusion criteria. There were six females (33%) and 12 males (p-value = 0.096). Age ranged between 27 and 82 years old (mean age 52.1 ± 17.3 years). Nine patients (50%) had a history of ipsilateral retinal detachment repair. Single E-PPV success rate was 100% after three months, and 94.4% at the latest follow up visit. Recurrent retinal detachment with posterior PVR occurred in one patient four months after surgery. Cataract progressed in 57% (8/14) of phakic patients, with 63% (5/8) undergoing cataract extraction surgery within the first postoperative year.

CONCLUSION

E-PPV enabled epiciliary membrane and anterior PVR visualization and removal. The single E-PPV success rate remained high at the latest follow up visit. E-PPV enabled the preservation of the phakic lens in all study patients. Larger prospective studies are needed on the role of E-PPV in retina surgeries.

Pre-operative intravitreal bevacizumab for tractional retinal detachment secondary to proliferative diabetic retinopathy: the Alvaro Rodriguez lecture 2023

The treatment of proliferative diabetic retinopathy (PDR) has evolved significantly since the initial use of panretinal photocoagulation as a treatment in the 1950s. Vascular endothelial growth factor inhibitors have provided an effective alternative without the risk of peripheral vision loss. Despite this, the risk of complications requiring surgical intervention in PDR remains high. Intravitreal bevacizumab has shown promise as a preoperative adjuvant to vitrectomy for PDR complications, albeit with a purported risk for tractional retinal detachment (TRD) progression in eyes with significant fibrous proliferation. Here we will discuss anti-VEGF agent use in PDR and its role in surgical intervention for PDR complications including TRD.

Tractional Retinal Detachment in Eyes with Vitreous Hemorrhage and Proliferative Diabetic Retinopathy and Posterior Vitreous Detachment in Fellow Eye

Purpose

To predict the presence of tractional retinal detachment (TRD) in eyes with dense vitreous hemorrhage (VH) and proliferative diabetic retinopathy (PDR) by evaluating the status of posterior vitreous detachment (PVD) in fellow eyes using optical coherence tomography (OCT).

Methods

A total of 44 eyes from 22 patients who underwent vitrectomy due to dense VH with PDR were enrolled. Using OCT, the PVD status in the fellow eye was divided into two groups (incomplete and complete PVD). The incomplete PVD group included eyes without PVD and eyes with partial PVD. B-scan ultrasonography (USG) was performed on eyes with dense VH to evaluate the presence of TRD. Both OCT and B-scan images were reviewed by four ophthalmologists (two novices and two experienced), and the inter-observer agreement was evaluated.

Results

There was a difference in the inter-observer agreement regarding the presence of TRD in eyes with dense VH evaluated by B-scan between novice and experienced ophthalmologists (novice, kappa = 0.421 versus experienced, kappa = 0.814), although there was no difference between novice and experienced ophthalmologists in the inter-observer agreement regarding the status of PVD in the fellow eye evaluated by OCT (novice, kappa = 1.000 versus experienced, kappa = 1.000). All observed TRD during vitrectomy occurred in eyes with incomplete PVD in the fellow eye. Logistic regression analysis revealed a statistically significant relation between TRD and the age of the patient (odds ratio [OR] = 0.874, p = 0.047), and between TRD and incomplete PVD in the fellow eye evaluated by OCT (OR = 13.904, p = 0.042).

Conclusion

Evaluation of the PVD status in the fellow eye using OCT may be a useful predictor for detecting the presence of TRD in eyes with dense VH and PDR.

Risk of Tertiary, Quaternary, and Quinary Proliferative Vitreoretinopathy: Analysis of a Nationwide Database (2010-2017)

OBJECTIVE

Primary proliferative vitreoretinopathy (PVR) is established as an important cause of the failed repair of a fresh retinal detachment (RD) and the consequent need for secondary repair. However, the burden of multiple repairs beyond the initial failure has not been studied in detail. We aimed to determine the association between primary PVR and the occurrence of tertiary, quaternary, and quinary RD repairs, using a nationwide database.

DESIGN

Retrospective cohort study of insurance claims.

SUBJECTS

Cases of rhegmatogenous RD that underwent primary surgical repair.

METHODS

Cases of primary RD repair from 2010 to 2017 were categorized based on the absence (P0 group) or presence (P1 group) of primary PVR. In each group, we analyzed the frequency of subsequent RD repair procedures with concurrent PVR.

MAIN OUTCOME MEASURE

The risk of secondary and higher multiples of PVR-associated RD repair.

RESULTS

A total of 27 137 cases were included, with 24 500 (90.3%) in the P0 group and 2637 (9.7%) in the P1 group. The frequency (%) of cases ultimately requiring secondary, tertiary, quaternary, and quinary repair in P0 versus P1 was 1.88 versus 10.24 (P < 0.001), 0.26 versus 2.50 (P < 0.001), 0.07 versus 0.64 (P < 0.001), and 0.03 versus 0.08 (P = 0.272), respectively. The risk of undergoing secondary repair was higher in the P1 than in the P0 group (hazard ratio [HR], 6.02; 95% confidence interval [CI], 5.24-6.92; P < 0.001). The risk of undergoing tertiary repair was also higher in the P1 than in the P0 group (HR, 1.67; CI, 1.23-2.28; P = 0.001). There was no difference in the risk of undergoing quaternary repair between the groups (HR, 0.76; CI, 0.41-1.40; P = 0.37). Senary repairs were not detected in this dataset.

CONCLUSIONS

Primary PVR may increase the risk of requiring multiple sequential retinal reattachment surgeries beyond the initial repair failure. Retinal detachment cases with primary PVR at the initial presentation of RD were more likely to undergo secondary and tertiary repairs than cases without primary PVR. Health care claims analysis may be a useful tool to study population-based estimates for multiple recurrences of RD in cases with PVR.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

A rare case of bilateral vitreoretinopathy of Aicardi syndrome

Purpose

To report a rare case of Aicardi syndrome presenting with concurrent peripheral retina nonperfusion with 360-degree neovascularization in the right eye and stalk tissue with a peripapillary fibrovascular membrane and tractional retinal detachment (TRD) in the left eye.

Observations

A one-month-old girl was referred for an ophthalmic evaluation to confirm the diagnosis of Aicardi syndrome due to abnormal brain magnetic resonance imaging. A 360-degree circumferential peripheral avascular retina with extensive neovascularization was present in the right eye. Stalk tissue with fibrovascular proliferation causing TRD was found in the left fundus. The retina of the right eye became quiescent after completing peripheral laser photocoagulation. The detached retina in the left eye was flattened, and the peripapillary chorioretinal lacunae became visible one year after surgical removal of the traction. In addition, the axial length growth of the left eye regained.

Conclusion and importance

This is a rare case of Aicardi syndrome with concurrent peripapillary fibrovascular traction in one eye and peripheral retina nonperfusion in the other eye. Surgical intervention is vital not only for removing the traction and flattening the retina but also for promoting continual growth of the eyeball.

The efficacy and safety of intravitreal injection of Ranibizumab as pre-treatment for vitrectomy in proliferative diabetic retinopathy with vitreous hemorrhage

Background

Intravitreal injection of anti-vascular endothelial growth factor (VEGF) has become first line therapy for diabetic macular edema. This study evaluated the efficacy and safety of intravitreal injection of Ranibizumab (IVR) as pre-treatment for pars plana vitrectomy in proliferative diabetic retinopathy (PDR) patients with vitreous hemorrhage.

Methods

This pilot randomized controlled trial included 48 eyes with vitreous hemorrhage resulting from active PDR. Eyes were treated with IVR 1 or 3 days before vitrectomy or a sham subconjunctival injection 3 days before surgery. The occurrence of new tractional retinal detachment (TRD), total operation time, and intraoperative findings were compared. The concentrations of VEGF and connective tissue growth factor (CTGF) in aqueous humor and plasma collected at the time of IVR and vitrectomy were determined by ELISA.

Results

None of the patients who received IVR experienced new TRD. Ranibizumab injection improved intraoperative outcomes. The mean concentrations of VEGF in aqueous humor were significantly lower after than before IVR in patients who received IVR 1 and 3 days before surgery (P < 0.001 each). The CTGF/log₁₀ (VEGF) ratio was significantly higher after than before IVR in patients who received IVR 3 days before vitrectomy (P = 0.046).

Conclusion

Preoperative IVR is an effective and safe strategy for the surgical treatment of severe PDR combined with vitreous hemorrhage. IVR 1 and 3 days before surgery can significantly reduce VEGF content in aqueous humor and effectively improve intraoperative conditions without causing TRD.

Trial registration

This study was registered with the Chinese Clinical Trial Registry. Name of the registry: Exploratory analysis of effect of intravitreal ranibizumab as pre-treatment for pars plana vitrectomy in proliferative diabetic retinopathy. Trial registration number: ChiCTR-ONC-16009520. Date of registration: October 20, 2016. URL of trial registry record: http://www.chictr.org.cn/searchprojen.aspx

Comparison of before versus after intravitreal bevacizumab injection, growth factor levels and fibrotic markers in vitreous samples from patients with proliferative diabetic retinopathy

PURPOSE

In diabetic retinopathy patients, intravitreal bevacizumab (IVB) injections are widely used to facilitate dissection of retinal fibrovascular membranes during surgery, reduce the rate of perioperative hemorrhage, and prevent recurrent neovascularization. Previous studies have shown that IVB may worsen fibrosis and thereby impair vision. The aim of this study was to determine which markers are associated with fibrosis.

METHODS

Twenty-three patients with proliferative diabetic retinopathy (PDR) underwent pars plana vitrectomy (PPV) with IVB pretreatment for intraocular hemorrhage (IOH) and/or tractional retinal detachment (TRD). Vitreous samples were obtained at the time of IVB injection and again at the beginning of PPV, about a week later. Using Western blot analysis, the concentrations of vascular endothelial growth factor (VEGF), placental growth factor (PIGF), insulin like growth factor-1 (IGF-1), angiogenin-1 (Ang-1), and vascular endothelial cadherin (VE-cadherin) were measured in vitreous samples.

RESULTS

After treatment with IVB, VEGF, PIGF, and VE-cadherin concentrations in the vitreous significantly decreased (p < 0.001, p < 0.001, and p = 0.001, respectively), whereas the concentrations of IGF-1 increased (p = 0.001). There were no significant changes in Ang-1 concentrations in the vitreous after IVB injection (p = 0.732). There were no statistically significant differences in VEGF-A, PIGF, VE-cadherin, IGF, and Ang-1 levels before and after IVB injection when the IOH and TRD groups underwent subgroup analysis (p = 0.696, p = 0.516, p = 0.498, p = 0.188, and p = 0.243, respectively).

CONCLUSION

The levels of VEGF and other cytokines changed in the vitreous after IVB. The adverse effects associated with IVB, such as fibrosis, may result from modulation of vitreous cytokine concentrations. In the treatment of PDR, drugs that optimize the effects of PIGF, IGF-1, and VE-cadherin to reduce these side effects may be useful.

Chorioretinal paracoccidioidomycosis treated with intravitreal voriconazole and therapeutic vitrectomy

Purpose

To report a case of aggressive chorioretinal paracoccidioidomycosis requiring treatment with systemic antifungal agents, frequent intravitreal voriconazole injections, and surgical excision.

Observations

A Brazilian man in his mid-30s with a history of chronic, biopsy-proven cutaneous paracoccidioidomycosis, chronic sinusitis, and perichondritis secondary to paracoccidioidomycosis presented with profound vision loss. He was found to have significant vitreous inflammation and a large chorioretinal lesion in the posterior pole concerning for ocular involvement. He was treated initially with combined topical and systemic steroids as well as systemic antifungals and antibiotics, then with serial intravitreal voriconazole injections resulting in a significant reduction of intraocular inflammation and subretinal fluid. The residual tractional retinal detachment from the chorioretinal lesion was addressed surgically by pars plana vitrectomy.

Conclusion and importance

Intravitreal voriconazole can be an effective adjuvant treatment for the vitreous inflammation and subretinal fluid associated with chorioretinal paracoccidioidomycosis. Surgical intervention may be indicated in cases complicated by tractional retinal detachment.

Case Report: Fibroglial Retinal Tissue in Contractile Morning Glory Disc Anomaly

The purpose of the present case is to describe a patient with tractional retinal detachment (RD) associated with contractile morning glory: a 17-year-old female, with a history of failed surgery for RD when she was 2 years old in her right eye (OD), nystagmus, and a limited visual acuity in the left eye (OS). The slit lamp examination showed phthisis bulbi in OD and the anterior segment was unremarkable in OS. Dilated fundus examination revealed a tractional RD in the posterior pole and peripapillary and preretinal fibrosis without evidence of intravitreal dispersion of retinal pigment epithelial cells. After surgery treatment, the RD resolved and the posterior segment showed a staphylomatous excavation around the optic disc anomaly with irregular contractions that folded the macular area. This were unrelated to light, breathing, or eye movements. Although morning glory disc anomaly is associated with RD, the early diagnosis can reverse structural changes. In this case, the rare association with contractile movements was found posterior to the pars plana vitrectomy after all the fibroglial epiretinal tissue was removed.

[Proliferative vitreoretinopathy process-To heal or not to heal]

BACKGROUND

Proliferative vitreoretinopathy (PVR) is still an unsolved problem after half a century of research.

METHODS

This article provides a review of mechanisms leading to PVR in the context of wound healing research.

RESULTS

Wound healing is a physiological repair process that occurs in a similar way in all organs and may end in scar formation. The development of PVR is based on this wound healing mechanism. The localization and structures involved lead to specific characteristics and consequences. Up to now the pharmacotherapeutic strategies were not sufficiently effective. The growing understanding of the mechanisms of scar-free fetal wound healing, could however lead to a solution of the PVR problem.

CONCLUSION

The PVR is a physiological process with a pathological result. The complex steps involved in vitreoretinal wound healing are well understood. There is currently no therapeutic approach neither in ophthalmology nor in other medical disciplines that is able to restore the original function and structure of the involved tissue or organ but there is hope that this can succeed in the future.

Adams Oliver syndrome: A mimicker of familial exudative vitreoretinopathy

Purpose

To describe an infant with Adams Oliver syndrome (AOS) with ocular signs similar to familial exudative vitreoretinopathy.

Observations

A full-term female infant presented with a congenital scalp defect, hypoplasia of the fingers and toes along with a radial retinal fold in the right eye and tractional retinal detachment in the left eye. Fluorescein angiography findings included peripheral retinal nonperfusion, irregular vascular sprouting beyond the vascular-avascular junction, pinpoint areas of hyperfluorescence as well as late peripheral and posterior vascular leakage. The patient was clinically diagnosed with Adams Oliver syndrome based on the collective findings. Laser photocoagulation to the avascular retina was performed in both eyes which resulted in stabilization of the condition after 2 years of follow up.

Conclusion and importance

The ocular phenotype in AOS may be similar to familial exudative vitreoretinopathy. Therefore, suspicion of the diagnosis should prompt ophthalmic evaluation including fluorescein angiography to detect and possibly treat the ischemic retinopathy.

Surgical outcomes of vitrectomy surgery for proliferative diabetic retinopathy in patients with abnormal renal function

PURPOSE

To analyse the influence of renal function on the outcomes of vitrectomy for tractional-related complications in cases of severe proliferative diabetic retinopathy (PDR).

METHODS

Retrospective consecutive case series of 109 eyes that underwent vitreoretinal interventions for traction-related complications of severe PDR from 2014 to 2017. Data collected included patient demographics, best-corrected visual acuity (BCVA), surgical complications, and systemic markers including HbA1c and estimated glomerular filtration rate (eGFR). Renal function categories were defined as low (eGFR < 30 mL/min/1.73 m²), medium (eGFR 30-60 mL/min/1.73 m²), and normal (eGFR > 60 mL/min/1.73m ²).

RESULTS

A total of 109 eyes (56% (n = 61) female) were included in the study. Overall, mean baseline BCVA improved from 1.33 logMAR to 0.91 logMAR (p < 0.001) postoperatively. Patients with low eGFR had significantly worse baseline BCVA (p = 0.039) and demonstrated greater improvement in mean BCVA (p = 0.059). Multivariate regression analysis indicated that seven predictors explained 65.5% of the variance (R² = 0.655, F(11,97) = 16.7, p < 0.01).

CONCLUSIONS

Reduced renal function does not adversely affect visual outcomes of vitrectomy for traction-related complications of PDR.

Long-term outcomes of sutureless 25-G+ pars-plana vitrectomy for the management of diabetic tractional retinal detachment

PURPOSE

To evaluate the short- and long-term surgical and clinical outcomes in eyes with diabetic tractional retinal detachment (TRD) undergoing 25-G+ pars-plana vitrectomy (PPV).

METHODS

A total of 238 patients were reviewed for inclusion in this study. A retrospective cohort study of 109 eyes of 73 patients operated on for diabetic TRD were included. All eyes received intraocular tamponade of air, sulfur hexafluoride, octofluropropane or silicone oil. All patients were followed up for a minimum period of one year.

RESULTS

The mean age of all patients at surgery was 53.9 years ± 9.2, while the mean duration of diabetes was 18.7 ± 10.4 years. The mean length of follow-up was 923 ± 87 days after surgery (range, 432-1792 days). Thirty-two cases (29.3 %) had an associated rhegmatogenous component. Mean BCVA improved from logarithm minimum angle of resolution (logMAR) 1.17 (20/300) to 0.812 (20/130) (p < 0.05). All eyes underwent intraoperative laser photocoagulation. Primary, single-surgery anatomic reattachment was achieved in 99 eyes (91 %). Final anatomic attachment was achieved in 107 eyes (98 %). There was no statistically significant difference in primary or secondary re-attachment rate in terms of type of tamponade agent used. There were five cases of post-operative hypotony (≤5 mmHg) on postoperative day 1, while 11 eyes had IOP ≥ 30 mmHg. There were no cases of endophthalmitis in our cohort.

CONCLUSIONS

25G+ PPV provides for safe and effective repair of diabetic TRDs. Patients experienced positive functional and anatomic outcomes, with no significant intraoperative complications and minimal postoperative sequelae.

Vitrectomy for Tractional Retinal Detachment with Twin Retinal Capillary Hemangiomas in a Patient with Von Hippel-Lindau Disease: A Case Report

Purpose

The purpose of this study was to report a case of Von Hippel-Lindau disease (VHL) with twin retinal capillary hemangiomas that was successfully treated by vitreous surgery for tractional retinal detachment following laser photocoagulation.

Case

A 44-year-old male presented at our university hospital after noticing decreased visual acuity in his right eye. The patient had previously undergone multiple operations for cerebellar, thoracic, and lumbar spine hemangioblastomas when he was approximately 19 years old. Upon initial examination, ocular findings revealed twin connected retinal capillary hemangiomas around the temporal upper area of the patient's right eye. The patient was subsequently diagnosed with VHL based on his medical history and current observations of the ocular fundus. Tractional retinal detachment had occurred as the result of the formation of proliferative membranes following laser photocoagulation. The patient underwent vitreous surgery to treat the tractional retinal detachment, resulting in a successful postoperative outcome.

Conclusion

The findings of this study show the possibility that proliferative changes and tractional retinal detachment can arise following photocoagulation for retinal capillary hemangiomas in patients with VHL.

Retinal ischaemia and delayed fibrovascular proliferation associated with an optic nerve coloboma

CASE REPORT

A patient with a left optic nerve coloboma with late development (at 15 years of age) of vitreoretinal fibrovascular proliferation and tractional retinal detachment (TRD). Sectorial retinal photocoagulation was performed with regression of the proliferative tissue and exudation.

DISCUSSION

Congenital optic nerve anomalies may be associated with significant retinal avascularity, ischaemia and late fibrovascular proliferation. Laser is effective for regression of the neovascular tissue and preventing TRD progression.

Perfluorocarbon in vitreoretinal surgery and preoperative bevacizumab in diabetic tractional retinal detachment

AIM: To describe the en bloc perfluorodissection (EBPD) technique and to demonstrate the applicability of using preoperative intravitreal bevacizumab during small-gauge vitreoretinal surgery (23-gauge transconjunctival sutureless vitrectomy) in eyes with advanced proliferative diabetic retinopathy (PDR) with tractional retinal detachment (TRD).

METHODS: This is a prospective, interventional case series. Participants included 114 (eyes) with advanced proliferative diabetic retinopathy and TRD. EBPD was performed in 114 eyes (consecutive patients) during 23-gauge vitrectomy with the utilization of preoperative bevacizumab (1.25 mg/0.05 mL). Patients mean age was 45 years (range, 21-85 years). Surgical time had a mean of 55 min (Range, 25-85 min). Mean follow up of this group of patients was 24 mo (range, 12-32 mo). Main outcome measures included best-corrected visual acuity (BCVA), retinal reattachment, and complications.

RESULTS: Anatomic success occurred in 100% (114/114) of eyes. Significant visual improvement [≥ 2 Early Treatment Diabetic Retinopathy Study (ETDRS) lines] was obtained in 69.2% (79/114), in 26 eyes (22.8%) BCVA remained stable, and in 8 eyes (7%) BCVA decreased (≥ 2 ETDRS lines). Final BCVA was 20/50 or better in 24% of eyes, between 20/60 and 20/400 in 46% of eyes, and worse than 20/400 in 30% of eyes. Complications included cataract in 32 (28%) eyes, iatrogenic retinal breaks in 9 (7.8%) eyes, vitreous hemorrhage requiring another procedure in 7 (6.1%) eyes, and phthisis bulbi in 1 (0.9%) eye.

CONCLUSION: This study demonstrates the usefulness of using preoperative intravitreal bevacizumab and EBPD during small-gauge vitreoretinal surgery in eyes with TRD in PDR.

[Use of bevacizumab in the treatment of complicated proliferative diabetic retinopathy]

INTRODUCTION

Diabetes is the leading cause of neovascular vitreoretinal proliferation. Several recent publications have appeared showing the efficacy and safety of intravitreal bevacizumab (IVT) in proliferative or complicated diabetic retinopathy (PDR), but with no consensus on the injected dose. We report the results of its use as adjuvant intravitreal injection (IVT) prior to posterior vitrectomy in the setting of complicated PDR. The goal of our work is to evaluate the benefits of and try to establish a protocol for proper use of intravitreal bevacizumab prior to vitrectomy for complicated PDR, so as to incorporate it in the management of this disease.

PATIENTS AND METHODS

A prospective comparative study of series of patients hospitalized for severe complicated PDR requiring vitrectomy was spread over one year, from January 2011 to December 2011. Included patients were divided into two groups: group A: receiving an injection preoperatively at a dose of 1.25mg, and group B, which received an injection of bevacizumab at a dose of 0.75mg (with a time to surgery of either less than 3 days, more than 6, or 3 to 6). We analyzed the epidemiological characteristics, data from the initial eye examination and intraoperative complications and follow-up after vitrectomy.

RESULTS

Thirty-five patients were included. We noted no significant difference in epidemiological characteristics between group A and B. Sixty percent of patients underwent surgery after a period of three to six days post-IVT. The reduction of neovascularization, decreased risk of bleeding and the facilitation of membrane peeling during surgery were significantly similar between group A and B. No complication related to the molecule and no recurrence, including bleeding, were noted throughout follow-up in both groups.

CONCLUSION

We opt for a systematic use of anti-VEGF, particularly bevacizumab prior to all vitrectomies for complicated PDR. A 0.75mg dose at an interval of 3 to 6 days seems to be a good compromise between the desired effect and possible complications that may arise.

Long-term results of lens-sparing vitrectomy for stages 4B and 5 retinopathy of prematurity

PURPOSE

To assess long-term anatomic and visual outcomes and associated complications of lens-sparing vitrectomy (LSV) for treatment of tractional retinal detachments (TRDs) associated with stages 4B and 5 retinopathy of prematurity (ROP).

METHODS

We performed a retrospective review of medical records and data analyses of consecutive patients who presented with stages 4B and 5 ROP and underwent LSV from 1999 to 2007. Retinal reattachment status, visual acuity and postoperative complications were evaluated.

RESULTS

Twenty-one eyes of 20 patients, including 13 eyes with stage 4B ROP and 8 eyes with stage 5 ROP, were examined. The mean follow-up period was 5.6 years. In 9 (43%) out of 21 eyes, retinas were eventually reattached. The anatomic success rates were 62% in stage 4B and 13% in stage 5 ROP. In eyes with reattached retinas, visual acuity better than form vision was shown in 7 eyes (78%), whereas no light perception was present in 10 eyes (83%) among eyes with TRD on final examination. Postoperative intraocular hemorrhage occurred in nine eyes (43%). Long-term complications of cataract, corneal opacity, glaucoma and strabismus developed in 4 (19%), 6 (29%), 7 (33%) and 8 (38%) eyes, respectively, and were more common in eyes with TRD.

CONCLUSIONS

After following-up for a mean of 5.6 years, the anatomical success rate of LSV was encouraging for the correction of TRD associated with stage 4B ROP but not for stage 5 ROP. Retinal reattachment is important for obtaining better visual outcomes and preventing the development of late complications.