Prospective Comparison of Surgery Outcome Between Preoperative and Intraoperative Intravitreal Injection of Ranibizumab for Vitrectomy in Proliferative Diabetic Retinopathy Patients

Comparing scleral wound suturing and non-suturing in 23-gauge vitrectomy combined with cataract phacoemulsification for the management of proliferative diabetic retinopathy

PURPOSE

To compare the outcomes of scleral wound suturing and non-suturing in 23-gauge vitrectomy combined with cataract phacoemulsification on eyes with severe proliferative diabetic retinopathy.

METHODS

This retrospective cohort study enrolled patients with proliferative diabetic retinopathy who underwent a 23-step vitrectomy combined with cataract phacoemulsification. Scleral wounds were either sutured or left unsutured in sutured group and unsutured group, respectively. All patients were monitored for 6 months, undergoing slit-lamp examination, intraocular pressure measurement, fundus examination, and vision assessment.

RESULTS

A total of 79 eyes were enrolled in sutured group and 85 eyes in unsutured group. Both groups were well-matched for factors such as age, sex, intraocular pressure (IOP), hypertension, diabetes duration, HbA1c levels, visual acuity, retinal detachment, neovascular glaucoma, and preoperative pan-retinal photocoagulation. Despite scleral incision sutures in sutured group, there was no significant difference in surgical time between the groups. Silicone oil and gas tamponade were similarly used, and no significant differences in postoperative complications were found, except that scleral suturing potentially exacerbated conjunctival or scleral scarring. Sutured group had a lower incidence of hypotony, though IOP was not significantly different between groups after one week. For silicone oil tamponade, IOP was comparable between groups, while for gas tamponade, early postoperative IOP was significantly lower in unsutured group. The incidence of postoperative hypotension was higher in unsutured group with gas tamponade. Visual acuity recovery showed no disparity between the groups.

CONCLUSION

For patients with proliferative diabetic retinopathy undergoing vitrectomy combined with cataract surgery, scleral incision suturing appeared to be more effective in maintaining intraocular pressure in the early stage, especially for those who had gas as the vitreous tamponade. However, this might worsened conjunctival or scleral scarring. There were no significant differences observed in postoperative complications and visual acuity recovery between patients with and without scleral wound suturing.

Updates on medical and surgical managements of diabetic retinopathy and maculopathy

Diabetic retinopathy (DR) and diabetic macular edema (DME) are leading causes of vision loss globally. This is a comprehensive review focused on both medical and surgical management strategies for DR and DME. This review highlights the epidemiology of DR and DME, with a particular emphasis on the Asia-Pacific region, urban-rural disparities, ethnic variations, and grading methodologies. We examine various risk factors for DR, including glycemic control, hypertension, hyperlipidemia, obesity, chronic kidney disease, sex, myopia, pregnancy, and cataract surgery. Furthermore, we explore potential biomarkers in serum, proteomics, metabolomics, vitreous, microRNA, and genetics that may aid in the detection and management of DR. In addition to medical management, we review the evidence supporting systemic and ocular treatments for DR/DME, including anti-vascular endothelial growth factor (anti-VEGF) agents, anti-inflammatory agents, biosimilars, and integrin inhibitors. Despite advancements in treatment options such as pan-retinal photocoagulation and anti-VEGF agents, a subset of cases still progresses, necessitating vitrectomy. Challenging diabetic vitrectomies pose difficulties due to complex fibrovascular proliferations, incomplete posterior vitreous detachment, and fragile, ischemic retinas, making membrane dissection risky and potentially damaging to the retina. In this review, we address the question of challenging diabetic vitrectomies, providing insights and strategies to minimize complications. Additionally, we briefly explore newer modalities such as 3-dimensional vitrectomy and intra-operative optical coherence tomography as potential tools in diabetic vitrectomy. In conclusion, this review provides a comprehensive overview of both medical and surgical management options for DR and DME. It underscores the importance of a multidisciplinary approach, tailored to the needs of each patient, to optimize visual outcomes and improve the quality of life for those affected by these sight-threatening conditions.

Pharmacological adjuvants for diabetic vitrectomy surgery

Diabetic vitrectomy is a highly intricate surgical procedure performed during the advanced stages of diabetic retinopathy (DR). It is used to treat conditions such as tractional or combined retinal detachment, vitreous hemorrhage, and subhyaloid hemorrhage, which are all severe manifestations of proliferative DR. The results of the surgery are uncertain and variable. Vitreoretinal surgery has made significant progress since the early stages of vitrectomy. In the past ten years, advancements in intravitreal pharmacotherapy have emerged, offering new possibilities to improve the surgical results for our patients. Within the realm of medical terminology, an "adjunct" refers to a pharmaceutical or substance employed to aid or expedite the primary therapeutic intervention for a particular ailment. Their introduction has broadened the range of therapeutic choices that are accessible prior to, during, and following surgical procedures. This review article will specifically analyze the pharmacological adjuncts used in diabetic vitrectomy surgery, with a focus on their role in facilitating or aiding specific steps of the procedure. The implementation of this system of categorization offers benefits to the surgeon by allowing them to foresee potential difficulties that may occur during the surgical procedure and to choose the appropriate pharmacological agent to effectively tackle these challenges, thus enhancing surgical success rates.

Vitrectomy for cases of diabetic retinopathy

Microvascular complications of diabetic retinopathy (DR) may require surgical intervention in the form of vitrectomy. Since its inception, diabetic vitrectomy has evolved with introduction of better instruments, newer techniques, and smaller port sizes. Common indications for diabetic vitrectomy include nonresolving vitreous hemorrhage, tractional retinal detachment, epiretinal membrane, progression of fibrovascular membranes despite laser therapy, recalcitrant diabetic macular edema, and neovascular glaucoma. Preoperative systemic stabilization is essential prior to planning surgery. Surgical techniques commonly used in diabetic vitrectomy are segmentation, delamination, and rarely en-bloc dissection. Modification in surgical techniques such as chandelier-assisted bimanual dissection and pharmacological adjuvants improve surgical outcomes in these patients. Prognosis in these patients could be improved with early intervention. Studies evaluating the outcome of vitrectomy in patients with early proliferative DR are required to understand the appropriate time of intervention in patients. Treatment aimed at arresting the progression of DR and gene therapy are avenues that need further evaluation. The following review will focus on covering the epidemiology of DR, indications of vitrectomy, preoperative considerations, surgical procedures of diabetic vitrectomy, methods of membrane dissection, pharmacological adjuvants to vitrectomy, outcomes of diabetic vitrectomy, and future directions of diabetic vitrectomy.

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.

Comparison of Clinical Profiles, Demographics, and Surgical Outcomes of 25-Gauge Vitrectomy for Proliferative Diabetic Retinopathy in Young Adults with Type 1 or Type 2 Diabetes

Purpose

Proliferative diabetic retinopathy (PDR) is a leading cause of poor vision in young adults. This study sought to evaluate the clinical characteristics and outcomes of primary vitrectomy for PDR in young adults.

Patients and Methods

Medical data were retrospectively collected at a large ophthalmology hospital in China. We analyzed data for 99 patients (140 eyes) aged <45 years with T1D or T2D who underwent primary vitrectomy for PDR-related complications.

Results

There were 18 patients with T1D and 81 patients with T2D. The proportion of males was significantly greater than that of females in both groups. The T1D group had a longer duration of diabetes (P = 0.008), younger age at primary vitrectomy (P = 0.049), and lower body mass index (P < 0.001) than the T2D group. The proportion of eyes with rhegmatogenous retinal detachment (RRD) was greater but the proportion of eyes with traction retinal detachment (TRD) was lower in the T1D group than in the T2D group. The final best-corrected visual acuity (BCVA) improved or remained stable in 100% and 85.3% of eyes and decreased in 0% and 14.7% of eyes in the T1D and T2D groups, respectively. After surgery, the incidence of postoperative complications was significant greater in the T2D group than in the T1D group (P = 0.045). Factors influencing the final visual acuity included preoperative BCVA in both groups, the duration of diabetes (P = 0.031) and preoperative FVP (P = 0.004) in the T1D group, and preoperative RRD (P < 0.001) and postoperative NVG (P < 0.001) in the T2D group.

Conclusion

In this retrospective study, young adults with T2D who underwent vitrectomy had worse final visual acuity and more complications than young adults with T1D.