Resolution of diabetic cystoid macular edema associated with spontaneous vitreofoveal separation

Surgical outcomes of vitrectomy for intractable diabetic macular edema

PURPOSE

To investigate clinical outcomes of vitrectomy for intractable diabetic macular edema (DME) in which anti-vascular endothelial growth factor (anti-VEGF) agents or periocular steroid were not effective.

METHODS

This retrospective study examined 27 eyes of 25 cases. The main measurements included changes in visual acuity (VA) and retinal morphology. Vitrectomies were performed using the Constellation System 25G.

RESULTS

Prior to undergoing vitrectomy, patients were treated with anti-VEGF agents or periocular injection of triamcinolone acetonide. The average number of anti-VEGF agent injections was 3.1 ± 2.8. Triamcinolone was used in 15 eyes. There was no significant change in the mean logMAR best-corrected visual acuity (BCVA) between baseline and posttreatment, with values of 0.49 ± 0.29 and 0.55 ± 0.33, respectively (P = 0.31). Compared with preoperative BCVA, postoperative BCVA improved by more than two lines in 4 eyes (14%), remained the same in 17 eyes (63%), and decreased in 6 eyes (23%). Morphologically, retinal thickness improved by more than 50 μm in 16 eyes (59%), remained unchanged in 7 eyes (26%), and increased in 5 eyes (18%). Retinal edema resolved in all of the cases in which macular epiretinal membrane (ERM) or vitreomacular traction (VMT) was detected by optical coherence tomography during pretreatment.

CONCLUSIONS

Vitrectomy can potentially stabilize the retinal morphology in intractable DME and is likely more effective in DME cases accompanied by ERM or VMT.

Outcome and Predictors for 2-Year Visual Acuity in Eyes with Diabetic Macular Edema Treated with Ranibizumab

Purpose: To determine the role of baseline characteristics in predicting visual outcome in patients with diabetic macular edema (DME) treated with ranibizumab. Methods: A review was carried out of the charts of 97 eyes that received pro re nata (PRN) intravitreal ranibizumab (IR) 0.5 mg treatment for DME. The change in the mean best-corrected visual acuity (BCVA) was analyzed. The baseline demographics and ocular and optic coherence tomography findings were analyzed to determine the association with the 2-year visual acuity (VA). Results: BCVA increased from 0.54 ± 0.2 (0.05-1.0) to 0.41 ± 0.3 (0.0-1.0) log of the minimum angle of resolution (P < 0.001). Age (P = 0.012), gender (P = 0.018), baseline BCVA (P < 0.001), presence of leaking microaneurysms (MA) (P = 0.018), development of vitreomacular traction (VMT) (P = 0.001), development of posterior vitreous detachment (PVD) (P = 0.040), and disruption of ellipsoid zone (EZ) (P = 0.007) were found as predictors of 2-year VA. There was no association between visual outcome and the other characteristics. Conclusions: PRN treatment of IR provides significant benefits in VA gain and anatomic improvement in eyes with DME. Older age, female sex, lower baseline VA, VMT development, and EZ disruption are predictors for the poor final VA. Development of PVD and leaking MA are predictors for the good final VA.

Diabetic macular edema: Evidence-based management

Diabetic macular edema (DME) is the most common cause of vision loss in patients with diabetic retinopathy with an increasing prevalence tied to the global epidemic in type 2 diabetes mellitus. Its pathophysiology starts with decreased retinal oxygen tension that manifests as retinal capillary hyperpermeability and increased intravascular pressure mediated by vascular endothelial growth factor (VEGF) upregulation and retinal vascular autoregulation, respectively. Spectral domain optical coherence tomography (SD-OCT) is the cornerstone of clinical assessment of DME. The foundation of treatment is metabolic control of hyperglycemia and blood pressure. Specific ophthalmic treatments include intravitreal anti-VEGF drug injections, intravitreal corticosteroid injections, focal laser photocoagulation, and vitrectomy, but a substantial fraction of eyes respond incompletely to all of these modalities resulting in visual loss and disordered retinal structure and vasculature visible on SD-OCT and OCT angiography. Efforts to close the gap between the results of interventions within randomized clinical trials and in real-world contexts, and to reduce the cost of care increasingly occupy innovation in the social organization of ophthalmic care of DME. Pharmacologic research is exploring other biochemical pathways involved in retinal vascular homeostasis that may provide new points of intervention effective in those cases unresponsive to current treatments.

Spontaneous Resolution of Vitreomacular Traction Associated with Diabetic Macular Edema

Purpose

Little information is available about the natural history of vitreomacular traction (VMT) associated with diabetic macular edema. A few cases of spontaneous resolution of VMT associated with diabetic macular edema have been described, but have not been documented by optical coherence tomography (OCT). The authors report the spontaneous resolution of VMT associated with diabetic macular edema 1 month after the end of panretinal photocoagulation therapy (PRP).

Methods

Case report: A 66-year-old woman presented with complicated proliferative diabetic retinopathy and diabetic macular edema associated with VMT, documented by OCT, in the right eye. Left eye examination showed complete PRP and ischemic maculopathy. PRP was immediately realized in the right eye in regard to the presence of complicated proliferative diabetic retinopathy.

Results

One month after the end of PRP, right eye visual acuity improved. OCT examination showed complete release of foveal posterior hyaloid traction, and significant reduction in foveal thickness. The follow-up was 1 year. At the end of follow-up, visual acuity slightly improved again; only a small residual foveal retinal thickening remained.

Conclusions

The authors report spontaneous resolution of VMT associated with diabetic macular edema, probably facilitated by PRP, with concurrent reduction of macular thickness and visual improvement. As spontaneous resolution may occur in some eyes with diabetic macular edema associated with VMT, a period of observation after the end of the PRP may be considered prior to vitrectomy.

Spontaneous Resolution of Vitreomacular Traction following Ranibizumab (Lucentis) Injection

Purpose

Spontaneous resolution of vitreomacular traction syndrome in diabetic patients is a rare phenomenon that has been poorly described in the literature.

Methods

Case presentation.

Results

The authors present a case of spontaneous resolution of vitreomacular traction following intravitreal administration of ranibizumab.

Conclusions

In patients with vitreomacular traction syndrome and diabetic macular edema, the combination of the possible vitreous liquefaction and mechanical increase of vitreous volume caused by an intravitreal injection with a degree of reduction in retinal thickness caused by the effect of vascular endothelial growth factor inhibition could play a role in the resolution of vitreomacular traction.

Interdigitation Zone Band Restoration After Treatment of Diabetic Macular Edema

PURPOSE

To investigate whether the integrity of the interdigitation zone band, the ellipsoid zone band, and the external limiting membrane are reliable markers of treatment outcome in diabetic macular edema (DME).

METHODS

In this retrospective study, we examined 41 treatment-naïve eyes (38 patients) with DME that were treated with laser therapy, pharmacotherapy, and/or vitrectomy. Best-corrected visual acuity and the integrity of the interdigitation zone band, the ellipsoid zone band, and the external limiting membrane were assessed before treatment and at 3, 6, and 12 months after DME treatment.

RESULTS

One year after treatment, the external limiting membrane, ellipsoid zone band, and interdigitation zone band were completely visible in 30 (73.2%), 24 (58.5%), and 2 (4.9%) eyes, respectively. Interdigitation zone band status improved significantly (P = 0.005) 1 year after treatment. The interdigitation zone did not improve in the absence of the ellipsoid zone band. Likewise, ellipsoid zone status did not improve in the absence of the external limiting membrane at any time after treatment.

CONCLUSION

The results of this study show that restoration of the interdigitation zone band constitutes a very sensitive marker of DME treatment outcome when the ellipsoid zone band is visible before treatment.

Posterior vitreous detachment: evolution and complications of its early stages

PURPOSE

To summarize emerging concepts regarding the onset and progression, traction effects, and complications of the early stages of age-related posterior vitreous detachment (PVD).

DESIGN

Interpretive essay.

METHODS

Review and synthesis of selected literature, with clinical illustrations, interpretation, and perspective.

RESULTS

Imaging of the vitreoretinal interface with optical coherence tomography has shown that PVD begins in the perifoveal macula. Recent longitudinal studies have demonstrated conclusively that early PVD stages persist chronically and progress slowly over months to years. Vitreous traction forces resulting from perifoveal PVD with a small vitreofoveolar adhesion (500 microm or less) may cause localized cystoid foveal thickening or one of several macular hole conditions. Traction associated with larger adhesion zones may cause or exacerbate a separate group of macular disorders. Ultrastructural studies suggest that epiretinal membrane develops from cortical vitreous remnants left on the retinal surface after PVD and plays an important role in traction vitreomaculopathies.

CONCLUSIONS

Age-related PVD is an insidious, chronic event that begins in the perifoveal macula and evolves over a prolonged period before vitreopapillary separation. Although asymptomatic in most individuals, its early stages may be complicated by a variety of macular and optic disc pathologic features, determined in part by the size and strength of the residual vitreoretinal adhesion.

Reduced concentrations of angiogenesis-related factors in vitreous after vitrectomy in patients with proliferative diabetic retinopathy

BACKGROUND

The purpose of this study was to determine whether vitrectomy alters the angiogenic profile in the vitreous of eyes with proliferative diabetic retinopathy (PDR).

METHODS

We measured the levels of angiopoietin-2, HGF, bFGF, PDGF, TIMP-1, and TIMP-2 by sandwich enzyme linked immunosorbent assay (ELISA) in vitreous samples from 27 eyes of 26 patients with PDR before pars plana vitrectomy (without IOL implantation) and in 12 fluid samples from 12 patients with PDR obtained during an IOL implantation 3.5 to 9 (mean 4.9) months after an earlier vitrectomy. The levels of these factors were also measured in 12 vitreous samples obtained from 12 eyes that had undergone epiretinal membrane (ERM) or macular hole (MH) surgeries.

RESULTS

The mean vitreous levels of both angiopietin-2 (103 pg/ml) and HGF (1091 pg/ml) in the sample from eyes with PDR collected at the time of the IOL implantation were significantly lower than in those collected before the vitrectomy (P < 0.01). On the other hand, the changes in the levels of TIMP-1 and TIMP-2 were both not significant after vitrectomy.

CONCLUSION

The significant decrease of angiopietin-2 and HGF in the vitreous fluid after vitrectomy suggests that vitrectomy shifts the eye towards an anti-angiogenic environment.

Optical Coherence Tomography Use in Evaluation of the Vitreoretinal Interface: A Review

Optical coherence tomography (OCT) is a valuable tool for assessment of the vitreoretinal interface. This article reviews the normal process of age-related posterior vitreous detachment as viewed by OCT. Abnormalities of the vitreoretinal interface as imaged by OCT are described including vitreomacular traction syndrome, cystoid macular edema/ diabetic macular edema, epiretinal membranes, full thickness macular holes, lamellar holes, pseudoholes, microholes, and schisis from myopia or optic pits/colobomas. This tool has given us new insights into the pathogenesis of these retinal abnormalities.

Ocular oxygenation and the treatment of diabetic retinopathy

Retinal photocoagulation and vitrectomy both reduce diabetic macular edema and neovascularization in diabetic retinopathy. We suggest that this clinical effect is based on the effect these treatment modalities have on retinal oxygenation, and we present a theory to explain why retinal photocoagulation and vitrectomy influence edema and neovascularization in diabetic and other ischemic retinopathies.

Retinal assessment using optical coherence tomography

Over the 15 years since the original description, optical coherence tomography (OCT) has become one of the key diagnostic technologies in the ophthalmic subspecialty areas of retinal diseases and glaucoma. The reason for the widespread adoption of this technology originates from at least two properties of the OCT results: on the one hand, the results are accessible to the non-specialist where microscopic retinal abnormalities are grossly and easily noticeable; on the other hand, results are reproducible and exceedingly quantitative in the hands of the specialist. However, as in any other imaging technique in ophthalmology, some artifacts are expected to occur. Understanding of the basic principles of image acquisition and data processing as well as recognition of OCT limitations are crucial issues to using this equipment with cleverness. Herein, we took a brief look in the past of OCT and have explained the key basic physical principles of this imaging technology. In addition, each of the several steps encompassing a third generation OCT evaluation of retinal tissues has been addressed in details. A comprehensive explanation about next generation OCT systems has also been provided and, to conclude, we have commented on the future directions of this exceptional technique.

Induction of posterior vitreous separation using LASIK suction ring may have a potential role in the management of diabetic macular edema

A significant percentage of patients with diabetic macular edema respond poorly to conventional laser photocoagulation. One associated factor in such patients with refractory diabetic macular edema is the absence of posterior vitreous detachment (PVD). Several invasive methods, such as surgical induction of PVD result in resolution of macular edema and improvement in visual acuity. Being invasive such modalities may have important surgical risks, such as retinal detachment and endophthalmitis. Recently, laser in situ keratomeilusis (LASIK), a well-accepted refractive procedure, has been reported to produce posterior vitreous detachment in patients with myopia. We herein hypothesize that application of LASIK suction ring, an external procedure, may be useful in the induction of PVD in patients with refractory diabetic macular edema and may have a better safety profile.

Optical coherence tomography assessment of the vitreoretinal relationship in diabetic macular edema

PURPOSE

To study the vitreoretinal relationship in diabetic patients with and without diabetic macular edema (DME) using optical coherence tomography.

DESIGN

Retrospective case-control study.

METHODS

setting: Institutional practice. patients: Thirty-five consecutive diabetic patients (49 eyes) with DME and 35 sex- and age-matched diabetic control patients without DME (49 eyes). observation procedure: All patients had Early Treatment Diabetic Retinopathy Study visual acuity measurement and biomicroscopic examination of the vitreoretinal interface. OCT was performed to obtain cross-sectional images of the vitreoretinal interface of the macular region. Posterior vitreous detachment (PVD) was staged from 0 to 3 as follows: stage 0: absence of PVD; stage 1: perifoveolar PVD with foveolar attachment; stage 2: incomplete PVD with residual attachment to the optic nerve; and stage 3: complete PVD. Retinal thickness was measured using OCT mapping software in all cases. main outcome measures: Prevalence of the different PVD stages in both groups of eyes.

RESULTS

The mean age of the patients was 60 years in both groups. Of the eyes with macular edema, 19 (38.8%) were stage 0, 26 (53.0%) stage 1, 1 (2.0%) was stage 2, and 3 (6.2%) were stage 3. In eyes without DME, the corresponding figures were, respectively, 34 (69.4%), 11 (22.4%), 1 (2.0%), and 3 (6.2%). The prevalence of perifoveolar PVD with foveolar attachment was significantly higher in the group of eyes with DME (P =.006).

CONCLUSIONS

These results show the high prevalence of perifoveolar PVD with foveolar attachment in diabetic patients with macular edema. Even though PVD is not the main factor involved in the pathogenesis of DME, perifoveolar PVD may have a role in the development of this complication.

Vitrectomy with internal limiting membrane removal for clinically significant macular oedema

BACKGROUND

Little has been published on internal limiting membrane (ILM) removal for clinically significant macular oedema (CSME) in eyes not improving following maximal laser treatment.

METHODS

Retrospective review of the charts and intraoperative video films of 30 consecutive eyes of 27 patients undergoing vitrectomy, ILM peeling, and gas tamponade by a single surgeon.

RESULTS

The average patient was 52 years old; 56% were males. The oedema was caused by diabetes in 87% of the eyes, 42% of which had proliferative disease. The oedema was diffuse in 16 eyes (53%) and cystoid (CME) in 14 (47%). In 21% of eyes, spontaneous vitreous detachment was present or the eye had already undergone vitrectomy. All but one eye had at least 6 months of follow-up (mean 12 months). The oedema resolved completely in 26 eyes (90%) and partially in 3 eyes (10%). The visual acuity improved at least two Snellen lines in 19 eyes (66%) and one line in 4 eyes (14%); the average improvement was 4 lines. The acuity was unchanged in three eyes (10%) and worsened in three eyes (10%), all due to cataract. Among the 14 eyes with CME, 11 (79%) became completely dry and the visual acuity improved in 11 eyes (79%). No ILM-related complication was encountered in any eye.

CONCLUSIONS

Vitrectomy with ILM peeling is a promising approach to eyes with CSME. It appears to offer visual improvement at a much higher rate than laser therapy and with a longer-lasting effect than that of intravitreal triamcinolone. A larger study is necessary to confirm these preliminary findings.

The correlation between fluorescein angiographic and optical coherence tomographic features in clinically significant diabetic macular edema

PURPOSE

To assess the correlation between the features of optical coherence tomography (OCT) and fluorescein angiography in clinically significant diabetic macular edema.

DESIGN

Retrospective observational case series.

METHODS

This study involved 145 eyes (91 patients) with clinically significant diabetic macular edema. The fluorescein angiography features were categorized into focal leakage type, diffuse leakage type, and diffuse cystoid leakage type. The OCT features were categorized into four types: type 1, thickening with homogeneous optical reflectivity; type 2, thickening with markedly decreased optical reflectivity in the outer retinal layer; type 3A, foveolar detachment without traction; and type 3B, foveolar detachment with apparent vitreofoveal traction. The correlation between fluorescein angiography types and OCT types were analyzed, and their associations with visual acuity, central foveal thickness. and stages of diabetic retinopathy were evaluated.

RESULTS

The prevalence of OCT type 1 was higher in the focal leakage type (73.0%) and in the diffuse leakage type (58.9%) than in the diffuse cystoid leakage type (3.8%) of fluorescein angiography (P <.0001). The prevalence of OCT type 2 and 3A was higher in the diffuse cystoid leakage type (57.7% and 34.6%, respectively) than in the focal leakage type (20.6% and 3.2%) or diffuse leakage type(28.6% and 10.7%; P <.0001). The stages of retinopathy correlated with fluorescein angiography types (P =.016). Optical coherence tomography type 1 and the focal leakage type of fluorescein angiography showed the least foveal thickness and the best visual acuity (P <.05).

CONCLUSIONS

There was a significant correlation between the features of OCT and fluorescein angiography in clinically significant diabetic macular edema. The combined data from both OCT and fluorescein angiography may provide a clearer understanding of the anatomic and physiologic characteristics of clinically significant diabetic macular edema.