Diabetic Tractional Detachment Research Articles

Silicone Oil Associated Complications in Vitreoretinal Surgery

Silicone oil is an effective tamponade that is still preferred in complicated retinal detachment cases such as giant retinal tears, proliferative vitreoretinopathy (PVR), diabetic tractional detachment, and traumatic detachment. After a variable period of tamponade, it is standard practice to remove the silicone oil. Because silicone oil stays in the eye for a long time causes many complications and problems in the intraocular structures. In this review, complications associated with silicone oil in vitreoretinal surgery are discussed.

Surgical Treatment Approaches and Membrane Peeling Techniques in Diabetic Tractional Detachment

Vitreoretinal surgeons usually classify diabetic tractional retinal detachments as macular/non-macular involvement. However, the conditions requiring surgical treatment in advanced diabetic patients have changed due to the technical and instrumentation developments that have occurred in the last 20 years, especially in vitreoretinal surgery. Non-regressive intravitreal hemorrhages, which are classic indications, have gone far beyond the indications of traction retinal detachment that holds the macula, and are moving to a stage where early vitrectomy will soon replace them.

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

BackgroundExtremes 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.MethodsThis was...

RETRACTED ARTICLE: Human amniotic membrane grafts for retinal breaks in diabetic tractional retinal detachment and combined tractional and rhegmatogenous retinal detachment

To describe the surgical outcomes of using human amniotic membrane (hAM) grafts in the management of retinal breaks in diabetic tractional detachment (TRD) and combined tractional and rhegmatogenous retinal detachment (CTRRD). A retrospective case series of 10 eyes with TRD or CTRRD receiving pars plana vitrectomy with hAM grafts implantation, compared with 13 controls receiving the same surgery without hAM grafts. Best-corrected visual acuity (BCVA) and re-detachment rate were compared between two groups. Postoperatively, all eyes in the hAM group had retina attachment without recurrence, while 9 eyes in the control group had retina re-detachment and required additional surgery (0% vs 69.2%, p = 0.003). The BCVA significantly improved in the hAM group (from 1.96 ± 0.95 to 1.44 ± 0.77 in log MAR, p = 0.03), but not improved in control group (p = 0.20). Postoperative optical coherence tomography of the eyes receiving hAM grafts demonstrated glial tissue regeneration and restoration of ellipsoid zone. In diabetic TRD or CTRRD, hAM grafts could be an effective method, with promising outcome. Compared to standard surgery, it could result in higher retina reattachment rate and significant visual improvement. Moreover, it may offer the adjunctive benefit in tissue regeneration and fasten ellipsoid zone restoration.

BIMANUAL MICROINCISION VITREOUS SURGERY FOR SEVERE PROLIFERATIVE DIABETIC RETINOPATHY: OUTCOME IN MORE THAN 300 EYES.

To evaluate the visual and anatomical outcomes and safety of bimanual microincision vitreous surgery for severe proliferative diabetic retinopathy. Retrospective review of 315 eyes of 282 patients who underwent 23-gauge or 25-gauge pars plana vitrectomy with bimanual membrane dissection for diabetic tractional detachment from January 2007 to September 2016. Minimum follow-up was 3 months, and the average duration of follow-up was 23 months (range 3-100 months; median 15 months). Outcome measures were best-corrected visual acuity, anatomical success, and postoperative complications. Postoperatively, 84.3% of eyes improved (>2 lines), 10.5% were stable, and 5.4% worsened (>2 lines). Comparing gauges, two-line improvement was seen in 87.4% of 23-gauge eyes compared with 79.7% of 25-gauge eyes (P = 0.029). Mean peak best-corrected visual acuity improved from 20/930 (1.67 ± 0.63) preoperatively to 20/120 (0.78 ± 0.63) postoperatively (P < 0.001). Primary reattachment was achieved in 310 eyes (98.4%) and final reattachment in 312 eyes (99%). Recurrent vitreous hemorrhage was the commonest postoperative complication (18.4%). Lower incidence of recurrent vitreous hemorrhage was seen with 25 gauge (13.5%) compared with 23 gauge (22%, P = 0.038). Epiretinal membrane formation (7.9%), intractable glaucoma (2.5%), and endophthalmitis (0.6%) were some of the other postoperative complications. Sustained visual improvement, anatomical restoration, and low complication rates were obtained in complex situations with bimanual microincision vitreous surgery in a large series. Visual outcomes were poorer in older age group, tractional retinal detachments involving macula, and eyes with extensive membranes and with silicone oil as tamponade. Both 23-gauge and 25-gauge groups were comparable in relation to visual improvement, anatomical success, and intraoperative and postoperative complications.

Black patients sustain vision loss while White and South Asian patients gain vision following delamination or segmentation surgery for tractional complications associated with proliferative diabetic retinopathy.

PurposeThis retrospective comparative case series aims to determine whether patient ethnicity (White versus South Asian versus Black) is related to the outcome of surgical treatment for traction complications of severe proliferative diabetic retinopathy (PDR).SettingMoorfields Eye Hospital London, UK.MethodsAll patients who underwent vitrectomy with, delamination and/or segmentation for PDR over a 5-year period (2009-2014) were reviewed retrospectively. Patients were divided into White, South Asian or Black groups, and their age, gender, HbA1C and type of diabetes were recorded. A total of 484 patients (253 White, 117 South Asian, 114 Black) were included. Twenty-one patients were excluded due to inadequate documentation.OutcomesLogMAR Visual acuity (converted from Snellen) (VA), was recorded pre-operatively and ~6 months post surgery (range 5-8 months). Surgical outcome was classified according to the type and duration of tamponade required post-operatively.ResultsPre-operative VA and HbA1C values were similar across all three ethnic groups (P=0.64 and 0.569, respectively). Change in VA (mean±SD) was 0.41±0.78, 0.14±0.76 and -0.26±0.57 in White, South Asian and Black patient groups respectively (P<0.001). Multiple regression analysis showed that post-op VA was significantly related to race and pre-op VA only (both P<0.001). The Black patient group were more likely to require silicone oil tamponade (P<0.001) and long-term retention of silicone oil (P<0.001) than the White and South Asian patient groups.ConclusionsThis study demonstrates that Black patients on average lose vision following delamination surgery for traction complications of PDR while White and South Asian patients gain vision. The same group is also at higher risk of retaining silicone more than 6 months after surgery. This difference remains even when corrected for glycaemic control. The higher risk of visual loss and long-term retention of silicone oil in black patients requires further investigation. If these results are confirmed, surgeons should consider their patients' ethnicity before proceeding with surgical treatment of diabetic tractional detachment.

Surgery for Proliferative Diabetic Retinopathy: New Tips and Tricks.

Over the recent years, retina specialists have enjoyed significant improvements in the surgical management of proliferative diabetic retinopathy including improved preoperative planning, vitreoretinal instrumentation and new surgical maneuvers. In this review, we present new tips and tricks such as preoperative pharmacotherapy approaches including pegaptanib injection and biodegradable dexamethasone implantation, bimanual vitrectomy techniques and the concept of mixing small gauges as well as valved cannulas and intraoperative optical coherence tomography. With advanced surgical planning and sophisticated operative maneuvers tailored to the individual patient, excellent outcomes can be achieved even in severe cases of diabetic tractional detachment.

This issue of Acta

This issue of <i>Acta</i>

Clinical variables and their relation to visual outcome after vitrectomy in eyes with diabetic retinal traction detachment.

To analyse vitrectomy results in diabetic eyes with retinal traction detachment and to investigate which variables are associated with a worse visual outcome. Forty-four diabetic eyes (33 patients) with central retinal traction detachment were analyzed retrospectively. After a median follow-up of 10 months, median visual acuity significantly improved from 20/800 to 20/160 (P=0.02), despite the fact that the majority of patients had a long-standing macular traction detachment (median 120 days). Twenty-two eyes (50%) achieved a visual acuity of >20/200. The retina was finally reattached in 38 eyes (86.3%). Univariate analysis showed that patients with type 2 diabetes, age older than 50 years, preoperative visual acuity <20/200, iris neovascularisation and macular detachment of >30 days had a significantly worse final visual outcome. After multiple logistic regression analysis, age and iris neovascularisation were the strongest predictors of a worse visual outcome; if both were present, the chance of a obtaining a visual outcome of <20/200 was almost 90%. Age and iris neovascularisation were the strongest predictors for a low visual outcome. In a review of vitrectomy studies in eyes with severe diabetic traction detachment in the past 2 decades, we found a trend towards higher anatomic success rates, while visual outcome only slightly improved. The current study confirmed the importance of ophthalmic variables, but also indicates the importance of evaluating systemic variables in larger series in order to predict which eyes may truly benefit from vitrectomy.

Results of penetrating keratoplasty in bullous silicone oil keratopathy

To evaluate the results of penetrating keratoplasty (PK) in bullous silicone oil keratopathy (BSK). PK for BSK was performed in 13 patients, aged from 31 to 82 years. In all patients, pars plana vitrectomy (PPV) with silicone oil implantation (SOI) had been previously performed as the definitive surgery: for complicated retinal detachment with advanced proliferative vitreoretinopathy in 12 eyes and for diabetic traction detachment in one eye. Seven patients were monocular. All 13 eyes were aphakic and there was a long-lasting contact of silicone oil with the corneal endothelium. Before keratoplasty, each eye underwent between two and five operations, on average three, for retinal detachment or late complications of SOI. The interval between SOI and PK was from 11 to 79 months. The patients were followed up for 12-52 months. At the last follow-up examination, a clear graft was found in 6 out of 13 eyes (46%). The six clear grafts were found in the ten eyes where silicone oil had been removed before keratoplasty. The graft became opaque in all three eyes in which silicone oil had not been removed. Six out of seven eyes with failed grafts atrophied. Visual acuity improved in all six eyes with the clear graft from had movement preoperatively to 0.05-0.25. The decreased visual acuity was caused by irreparable damage to the macula, which resulted from high myopia, proliferative vitreoretinopathy or long-lasting detachment of the macula. PK in BSK was successful only in those eyes in which the attached retina enabled the removal of the silicone oil before the PK. The reattached retina and useful visual acuity before the development of BSK were the preconditions for functional success of the PK.

Initial Clinical Experience With an Erbium:YAG Laser for Vitreoretinal Surgery

We tested the efficacy of an erbium:YAG laser for maneuvers in patients undergoing vitreoretinal surgery. An erbium:YAG laser equipped with a flexible fiberoptic and interchangeable 20-gauge endoprobes of various tip configurations ranging from 100 to 365 microns was used for specific maneuvers in 13 patients referred for vitreoretinal surgery for diabetic traction detachment, proliferative vitreoretinopathy, retinal detachment with posterior break, and epimacular membrane. The following maneuvers were performed: (1) transection of elevated vitreous membranes, (2) incision of epiretinal membranes, (3) drainage and relaxing retinotomy, (4) transection of subretinal membranes, (5) noncontact ablation of epiretinal membranes in air-filled eyes, (6) ablation of lens remnants, (7) posterior capsulotomy, (8) iris surgery, and (9) retinal vascular coagulation. Forty-eight defined maneuvers were performed with energy levels ranging from 0.2 to 5.0 mJ and repetition rates of 2 to 30 Hz. Transection of elevated membranes, subretinal membranes, and retinotomies were easily performed. Fourteen incisions into vascularized epiretinal membranes in diabetic traction detachment surgery demonstrated a fine margin of coagulation that permitted hemostatic incision. Retinal breaks were created during one of these incisions. Lens remnant ablation, posterior capsulotomy, and iris tissue removal were successful, with a single complication consisting of damage to the posterior surface of an intraocular lens during a pars plana posterior capsulotomy accomplished by means of a side-firing probe. Epiretinal membrane ablations in air-filled eyes were effectively performed in a gradual fashion without hemorrhage. The erbium:YAG laser offers precise and effective tissue cutting and removal in vitreoretinal maneuvers. Further study will determine the role of this technology in vitreoretinal surgery.

VITRECTOMY FOR DIABETIC TRACTION RETINAL DETACHMENT INVOLVING THE MACULA

We analyzed the surgical results for 197 eyes that underwent vitrectomy for diabetic traction detachment of the macula. The retina was successfully reattached in 130 of the 197 cases (66%), although the final level of vision depended on the amount of permanent macular damage from the previous detachment and on the effects of the retinal vascular disease. At the final examinations, 112 eyes (57%) had improved visual acuities, 68 eyes (35%) were worse, and 17 eyes (9%) were unchanged. Thirteen eyes (7%) had final visual acuities of 20/40 or better, 103 eyes (52%) had final visual acuities of 20/50 to 20/800, and 81 eyes (41%) had final visual acuities worse than 20/800. Two preoperative factors were associated with a worse prognosis for achieving a final visual acuity of 20/800 or better: preoperative vitreous hemorrhage (P < .01) and the absence of preoperative scatter retinal photocoagulation (P < .01). Additionally, two surgical factors, lens removal and the creation of iatrogenic retinal breaks, were associated with a poorer visual prognosis (P < .002 and P < .01, respectively). The group of eyes that underwent lens removal during vitrectomy also had a significantly higher incidence of postoperative iris neovascularization compared to eyes in which the lenses were not removed (P < .05).

Der Einfluß von Rubeosis iridis und aktiven Neovaskularisationen am Fundus auf die Ergebnisse der Glaskörperchirurgie bei der proliferativen diabetischen Retinopathie

To determine the influence of preoperative rubeosis iridis and active neovascularization at the fundus on surgical results, the authors analyzed a consecutive series of 85 eyes that underwent vitrectomy for diabetic tractional detachment of the macula. Minimum follow-up was 12 months. Rubeosis was present in 51%, active neovascularization at the fundus in 82%. Surgery was performed under Spitznas wide-angle observation using a stereoscopic diagonal inverter either with the panfundoscope or binocular ophthalmoscopy through the operating microscope. In the 93% of the eyes that were phakic no lensectomy was performed. Anatomical success was achieved in 79%, ambulatory vision in 74%. Anatomical success was reduced to 58% in cases with preoperative rubeosis and to 70% in cases with active neovascularization at the fundus. Including four cases of re-vitrectomy, silicone oil was used for internal tamponade in 9%, SF 6/air 50:50 in 38% and air in 28%. In 25% no internal tamponade was applied. Postoperative complications included vitreous bleeding (21%), increased rubeosis (20%), neovascular glaucoma (2%), redetachment (6%), rubeosis/hypotony/cataract (13%) and phthisis (3.5%). In 21% of the eyes the final result of surgery was failure, due to redetachment (3.5%), neovascular glaucoma (1%), rubeosis/hypotony/cataract (13%) and phthisis (3.5%).

Vitreoretinal dissection set.

We developed and evaluated a vitreoretinal dissection set consisting of six microspatulas, a specially designed micro-olive tip, an internal drainage cannula, and a master handle. The microspatulas, which have a spear-headed shape with blunt edges and flat, smooth surfaces, offer a range of angulation from 60 degrees to 160 degrees as well as options for front, back, or tip opening for irrigation or aspiration purposes. All parts can be used through conventional 20-guage or 19-guage sclerostomies, and they all fit on the same handle as well as on any Luer lock system. This set allows for mechanical and/or hydraulic dissection, membrane engagement by suction, and simultaneous use of probe with scissors or forceps. It has been proved safe and effective in more than 100 vitrectomies, including cases of diabetic tractional detachment, proliferative vitreoretinopathy, retrolental fibroplasia, and macular pucker.

Histology and therapy of diabetic traction detachment

Diabetic tractional detachment of the retina is caused by shrinking processes of the vitreous, which at most detaches only partially, and by shrinking of epiretinal proliferations. The shrinking of the vitreous results in tractional forces working centripetally and toward the base of the vitreous. The shrinking of the epiretinal proliferations, however, results in a tangential gathering of the retina. The two processes are usually found together in diabetic tractional retinal detachment. Treatment consists of a vitrectomy to eliminate the centripetal forces and tractions to the vitreous base. Further relief and unfolding of the retina is achieved by segmentation of the epiretinal membranes. Additional conventional retinal surgery procedures and implantation of silicone oil may become necessary in especially unfavorable cases. The surgical technique is explained with examples of typical situations.

Vitrectomy for Diabetic Traction Retinal Detachment Involving the Macula

We analyzed the surgical results for 197 eyes that underwent vitrectomy for diabetic traction detachment of the macula. The retina was successfully reattached in 130 of the 197 cases (66%), although the final level of vision depended on the amount of permanent macular damage from the previous detachment and on the effects of the retinal vascular disease. At the final examinations, 112 eyes (57%) had improved visual acuities, 68 eyes (35%) were worse, and 17 eyes (9%) were unchanged. Thirteen eyes (7%) had final visual acuities of 20/40 or better, 103 eyes (52%) had final visual acuities of 20/50 to 20/800, and 81 eyes (41%) had final visual acuities worse than 20/800. Two preoperative factors were associated with a worse prognosis for achieving a final visual acuity of 20/800 or better: preoperative vitreous hemorrhage (P less than .01) and the absence of preoperative scatter retinal photocoagulation (P less than .01). Additionally, two surgical factors, lens removal and the creation of iatrogenic retinal breaks, were associated with a poorer visual prognosis (P less than .002 and P less than .01, respectively). The group of eyes that underwent lens removal during vitrectomy also had a significantly higher incidence of postoperative iris neovascularization compared to eyes in which the lenses were not removed (P less than .05).

Diabetic Traction Detachment

One hundred thirty-six of 124 patients with diabetic traction detachment (TD) were observed for an average of 4.6 years (range, 3.0 to 9.4 years) with no surgical intervention. Visual acuity was maintained or improved in 51 of these eyes; 71 continued to be 20/200 or better. Diabetic TDs remained stable for long periods, those of more severe grade being more stable. At final examination, 60% (81/136) were graded at the same anatomic level (36/136) or an improved level (45/136). Spontaneous reattachment occurred in 20% (27/136); 78% (21/27) of these eyes had small detachments (TD1). The status of the vitreous and the vitreoretinal adhesion determined both the degree of detachment and the incidence of spontaneous reattachment.