Tractional Retinal Detachment Research Articles

Does addition of intravitreal bevacizumab confer additional benefit in management of proliferative diabetic retinopathy?

To evaluate visual outcome and complications of PDR after treatment with Intravitreal Bevacizumab followed by Pan Retinal Photocoagulation A hospital based retrospective study was done in the Department of Ophthalmology, to evaluate visual outcome and complications of PDR after treatment with intravitreal Bevacizumab followed by Pan Retinal Photocoagulation. Visual Acuity, Dilated fundus examination, OCT macula were done on subsequent follow ups 135 eyes of 133 patients were included in the study.The mean pre procedure visual acuity is 0.639±0.5327 which improved to 0.451±0.4089 post procedure. P value is <0.001 which is statistically significant.i.e, 94 (69.62%) eyes had improved vision, 21(15.55%) had stable vision and 20(14.81%) eyes had decreased vision. After injection followed by PRP out of 135 eyes,4(2.96%) eyes developed vitreous hemorrhage which resolved with repeat intravitreal anti-VEGF injection, 6(4.44%) eyes developed diabetic macular edema,3(2.2%) eyes developed Neovascularisation of iris and 4(2.96%)eyes developed vitreous hemorrhage with traction retinal detachment.From our study it appears that addition of intravitreal anti VEGF to Pan Retinal Photocoagulation for PDR confers the additional benefit of less incidence of vitreous hemorrhage and less incidence of traction retinal detachment requiring surgery in the 1 one year of follow up. This amounts to more compliance by the patient for taking the treatment as well as better visual outcome

Beyond VEGF: Angiopoietin–Tie Signaling Pathway in Diabetic Retinopathy

Complications from diabetic retinopathy such as diabetic macular edema (DME) and proliferative diabetic retinopathy (PDR) constitute leading causes of preventable vision loss in working-age patients. Since vascular endothelial growth factor (VEGF) plays a major role in the pathogenesis of these complications, VEGF inhibitors have been the cornerstone of their treatment. Anti-VEGF monotherapy is an effective but burdensome treatment for DME. However, due to the intensive and burdensome treatment, most patients in routine clinical practice are undertreated, and therefore, their outcomes are compromised. Even in adequately treated patients, persistent DME is reported anywhere from 30% to 60% depending on the drug used. PDR is currently treated by anti-VEGF, panretinal photocoagulation (PRP) or a combination of both. Similarly, a number of eyes, despite these treatments, continue to progress to tractional retinal detachment and vitreous hemorrhage. Clearly there are other molecular pathways other than VEGF involved in the pathogenesis of DME and PDR. One of these pathways is the angiopoietin–Tie signaling pathway. Angiopoietin 1 (Ang1) plays a major role in maintaining vascular quiescence and stability. It acts as a molecular brake against vascular destabilization and inflammation that is usually promoted by angiopoietin 2 (Ang2). Several pathological conditions including chronic hyperglycemia lead to Ang2 upregulation. Recent regulatory approval of the bi-specific antibody, faricimab, may improve long term outcomes in DME. It targets both the Ang/Tie and VEGF pathways. The YOSEMITE and RHINE were multicenter, double-masked, randomized non-inferiority phase 3 clinical trials that compared faricimab to aflibercept in eyes with center-involved DME. At 12 months of follow-up, faricimab demonstrated non-inferior vision gains, improved anatomic outcomes and a potential for extended dosing when compared to aflibercept. The 2-year results of the YOSEMITE and RHINE trials demonstrated that the anatomic and functional results obtained at the 1 year follow-up were maintained. Short term outcomes of previously treated and treatment-naive eyes with DME that were treated with faricimab during routine clinical practice suggest a beneficial effect of faricimab over other agents. Targeting of Ang2 has been reported by several other means including VE-PTP inhibitors, integrin binding peptide and surrobodies.

Surgical outcomes in concurrent sickle cell and diabetic retinopathy

Purpose: To report the clinical features and outcomes in eyes that underwent vitreoretinal surgery for complications of concurrent sickle cell retinopathy (SR) and diabetic retinopathy (DR). Methods: Retrospective, consecutive case series of all eyes that underwent vitreoretinal surgery for complications secondary to concurrent SR and DR between 1/1/2014 and 12/31/2021. Results: The study included 20 eyes of 14 patients. Indications for surgery included tractional retinal detachment (TRD) in 12 (60%) eyes, combined TRD/rhegmatogenous retinal detachment in 6 (30%) eyes, and vitreous hemorrhage in 2 (10%) eyes. Pars plana vitrectomy (PPV) was performed in all eyes. One eye received a scleral buckle at the same time as PPV. There was no change in mean BCVA at last follow-up examination (1.5 [20/678]) when compared to mean preoperative BCVA (1.6 [20/762], P = 0.83). Preoperative BCVA correlated with postoperative BCVA at last follow-up examination in eyes with retinal detachment (r = 0.49, P = 0.04). Single operation anatomic success was achieved in 11 of 17 (65%) eyes with retinal detachment. Conclusion: Functional and anatomic outcomes after surgery in eyes with concurrent SR and DR are relatively poor.

Ophthalmic artery ischemia in hemophagocytic lymphohistiocytosis: A case report and review of current literature

Introduction: This case report describes the ocular manifestations of hemophagocytic lymphohistiocytosis in a 35-year-old male with suspected Adult-onset Still’s Disease. Documented ocular presentations of hemophagocytic lymphohistiocytosis are variable, and the pathophysiology remains unclear. A complete review of the current literature suggests that posterior segment findings, including retinal and vitreous hemorrhage, are most common. Case Report: Here we describe the first published case of bilateral combined choroidal and retinal ischemia in a patient with ocular hemophagocytic lymphohistiocytosis. This is suggestive of complete ophthalmic artery occlusion driving proliferative retinopathy. Mechanistic hypotheses include anemia, thrombocytopenia, coagulopathy, and histiocytic infiltration. Conclusion: In this case, pre-retinal hemorrhage, retinal hemorrhage, and vitreous hemorrhage were treated with panretinal photocoagulation, pars plana vitrectomy, and bevacizumab at different stages in each eye. Unusually for ocular hemophagocytic lymphohistiocytosis, the patient developed a unilateral tractional retinal detachment, later thought to be due to early administration bevacizumab prior to vitrectomy in the left eye. Final visual acuity in this patient remains poor, and worse in the left eye. We therefore suggest early vitrectomy to maintain adequate views of the fundus before bevacizumab or panretinal photocoagulation in this patient cohort.

The effect of adjuvant Mitomycin C during vitrectomy on functional and anatomical outcomes in patients with severe diabetic tractional retinal detachment.

To evaluate the effect of adjuvant Mitomycin C (MMC) use on the anatomical and functional success of vitreoretinal surgery (VRS) in severe diabetic tractional retinal detachment (dTRD) patients. A retrospective analysis of consecutive patients undergoing VRS due to severe dTRD was conducted. Patients were categorized into those who received 20µg/0.1mL MMC via MMC sandwich method (Group 1) and those who did not (Group 2). Demographics, surgical characteristics, visual outcomes, and complications that may related to MMC were analyzed. A total of 25 eyes were included, 13 in Group 1 and 12 in Group 2. No statistical difference was observed in baseline characteristics between the groups. The mean best-corrected visual acuity was 1.90 ± 0.43 logMAR and 1.93 ± 0.41 logMAR preoperatively and 1.60 ± 0.78 logMAR and 1.56 ± 0.78 logMAR postoperatively in Groups 1 and 2, respectively (p = 0.154). The postoperative mean intraocular pressure was 16.23 ± 2.55mmHg and 13.08 ± 4.94mmHg in Groups 1 and 2, respectively (p = 0.225). The rate of re-surgery was significantly lower in Group 1 (0% vs. 41.7% in Group 2, p = 0.015). Retina was attached in all patients at the last visit. No MMC-related complication was recorded. Intraoperative adjuvant MMC application for severe dTRD significantly reduces re-surgery rates with good anatomical and functional outcomes safely.

A Case of Rapidly Progressive Proliferative Diabetic Retinopathy in the Setting of Severe Anorexia Nervosa

Purpose: To report a case of rapidly progressive diabetic retinopathy in the setting of admission for severe anorexia nervosa. Methods: Case report Results: A 21-year-old female with type 1 diabetes mellitus and mild nonproliferative diabetic retinopathy of both eyes was admitted for severe anorexia nervosa with a BMI of 12.5 and hemoglobin A1c of 10.6. Three months after admission, the patient reported visual complaints and was found to have severe nonproliferative diabetic retinopathy in the right eye and proliferative diabetic retinopathy with vitreous hemorrhage in the left eye. She was lost to follow-up for 4 months, then presented to clinic with bilateral proliferative diabetic retinopathy and a tractional retinal detachment of the right eye. Conclusion: There is a potential relationship between severe eating disorders and rapid worsening of diabetic retinopathy. Patients with type 1 diabetes who have acute complications due to eating disorders should be evaluated by an ophthalmologist to monitor for rapid progression of retinopathy.

Aggressive Onset of a Progressive FEVR Phenotype in a Child With Novel Mutations in LRP5 and TSPAN12

Purpose: To describe a patient with familial exudative vitreoretinopathy (FEVR) and the treatment course. Methods: A case was evaluated. Results: A 3-year-old boy presented with severe onset of FEVR, with a subhyaloid hemorrhage in 1 eye and tractional retinal detachment (TRD) in the fellow eye. Aggressive treatment with retinal photocoagulation and repeated injections of intravitreal bevacizumab resulted in stability of the retinal disease. Lens-sparing vitrectomy was performed for the TRD. The treatment effect was durable, and the patient retained useful vision in the better eye at 19 years of age. A subsequent genetic analysis showed 2 novel heterozygous missense mutations in LRP5 and TSPAN12. Conclusions: The presence of 2 novel mutations associated with severe FEVR identified in our patient is in agreement with in vitro studies showing that a more severe reduction in Norrin/β-catenin signal activity occurs with the combination of 2 mutations.

Retrospective case series of high-density silicone oil (Oxane HD) in severe proliferative vitreorretinal retinal detachment patients

BackgroundDescribe complications and clinical outcomes of heavy silicone oil (HSO) Oxane HD® use as an alternative to overcome the challenges of performing vitrectomy to treat tractional and rhegmatogenous retinal detachments with proliferative vitreoretinopathy (PVR).MethodsA retrospective, observational study was performed on patients from one center from August 2014 to Aug 2023. It was included patients who underwent surgery using HSO Oxane HD® to treat rhegmatogenous retinal detachment with PVR or mixed tractional and rhegmatogenous diabetic retinal detachment. Severely ill patients who could not attend to follow up were excluded. The primary outcome was successful retinal attachment at first postoperative month. A descriptive analysis was performed.ResultsAmong the 31 patients, 29 (93.5%) underwent surgeries due to rhegmatogenous retinal detachment and two (6.5%) for diabetic retinal detachment. The primary anatomic success was achieved in 27 (87.1%) patients. At the final visit, 17 (56.6%) had vision better than 20/400 (range, 20/30 to light perception). The vision was stable or improved in 22 (76.8%) patients at the end of follow-up. Nineteen (61.3%) patients required hypotensive eye drops after HSO use and twelve (38.7%) still required hypotensive eye drops at the final follow-up; three (9.7%) patients required additional glaucoma surgeries.ConclusionsHSO is safe and useful for complex retinal detachments cases specially with inferior tears and PVR. Ocular hypertension is frequent and usually clinically controlled with hypotensive eyedrops. Close postoperatively follow-up is advised due to the ocular complications, particularly elevated intraocular pressure and emulsification.

Traumatic terson syndrome with a peculiar mass lesion and tractional retinal detachment: a case report

BackgroundTo report a case with bilateral Terson syndrome presented with a unique mushroom-like mass lesion on the optic disc along with proliferative vitreoretinopathy and tractional retinal detachment.Case presentationA 33-year-old man was injured during a traffic accident and had diffuse brain swelling and intraocular hemorrhage. Poor vision in both eyes was noted after the patient regained consciousness. B-scan ultrasonography showed extensive vitreous opacity with a posterior vitreous detachment and without obvious retinal detachment. Vitrectomy was performed in both eyes five months after the accident. After clearing up the vitreous opacity, a peculiar pigmented mushroom-like mass lesion was noted in the posterior pole and had severe adhesion to the underneath optic disc. Extensive multilayered peripapillary epiretinal membrane was found covering the posterior pole and led to tractional retinal detachment around the macula. The mass was presumed to be an organized vitreous hemorrhage originated from the optic disc. The extensive and adherent epiretinal membrane together with the mass lesion were removed as much as possible and silicon oil was injected for tamponade. However, in the right eye, the retina redetached under silicon oil, whereas in the left eye, his vision improved to 20/100.ConclusionsTerson syndrome usually has a favorable prognosis but may be complicated by proliferative vitreoretinopathy and tractional retinal detachment. Careful monitoring is warranted and early vitrectomy should be considered in cases suspecting additional pathologies.

Trimanual vitrectomy versus bimanual vitrectomy in tractional proliferative diabetic retinopathy

ABSTRACT Objective To evaluate the impact as well as safety of trimanual vitrectomy versus bimanual vitrectomy in cases with complicated proliferative diabetic retinopathy (PDR) necessitating surgical intervention. Methods We designed a randomized, interventional, prospective study on 40 pseudophakic eyes suffering from tractional retinal detachment (TRD). 20 eyes of 16 cases with trimanual 23-gauge Parsplana vitrectomy (PPV) were categorized as Group A ”trimanual group.” Twenty eyes of 18 cases with bimanual 23-gauge PPV were categorized as Group B” bimanual group” in the duration between May 2021 and December 2022. All cases were under continual observation for ≥ 6 months postoperatively. Results A total of 40 eyes out of 34 cases with the mean age of cases 50.5 years (ranged between 29–69 y) in group A and 47.9 (ranged between 33–60 y) old in group B were assessed. Retinal attachment, total elimination of the pre-retinal proliferation attained in all cases of the two groups. Surgical time was statistically significant shorter in the trimanual group compared to bimanual group (p value < 0.05). Both groups gained statistically significant better vision. The mean pre-operative VA (Visual acuity) in group A was 1.75 (Log MAR) and 1.59 in group B, whereas the mean final visual outcome 6 months following operation was 0.73 in the 1st group & 0.82 in the 2nd one (p value < 0.001*). Conclusion Trimanual PPV is a safe as well as efficient approach that may ameliorate the result of vitrectomy in tractional PDR.

Ocular blood flow in preterm neonates

Retinopathy of prematurity (ROP) is a disorder affecting low birthweight, preterm neonates. In the preterm eye, the retina is not fully developed and neovascularization may occur at the margin between the developed vascular retina and undeveloped avascular retina. Without timely treatment by laser or intravitreal anti-vascular endothelial growth factor (VEGF) therapy, this can lead to tractional retinal detachment and blindness. Visualization of the retina in regular examinations by indirect ophthalmoscopy is hence the current standard of care, but the exams are stressful and interpretation of images is subjective. The upregulation of VEGF in ROP would suggest an increase in ocular blood flow. In this report, we evaluate the potential of ultrafast plane-wave Doppler ultrasound (PWU) to detect increased flow velocities in the orbital vessels supplying the eye in a gentle exam with objective findings. We imaged both eyes of 50 low-birthweight preterm neonates using 18 MHz PWU. Flow velocity in the central retinal artery (CRA) and vein (CRV), and the short posterior ciliary arteries were determined and values at each ROP Stage compared. We found significantly increased velocities in the CRA and CRV in Stage 3 ROP eyes, where intervention would be considered. We compared multivariate models for identifying Stage 3 eyes comprised solely of clinical factors, solely of Doppler parameters, and clinical plus Doppler parameters. The respective models provided areas under their respective ROC curves of 0.760, 0.812, and 0.904. PWU Doppler represents a gentle, objective means for identifying neonates at risk for ROP that could complement ophthalmoscopy.

Associations between lipid abnormalities and diabetic retinopathy across a large United States national database.

While dyslipidaemia has been suggested as a potential risk factor for diabetic retinopathy (DR), previous studies have reported conflicting findings. This study aimed to better characterize the relationship between abnormal serum levels of various lipid markers and the risk of the development and progression of DR. This retrospective cohort study utilized a United States national database of electronic medical records. Adults with a history of type 2 diabetes mellitus without type 1 diabetes mellitus were divided into cohorts based on the presence of abnormal serum levels of various lipid markers. Propensity score matching was performed to match cohorts with abnormal lipid levels to those with normal lipid levels on covariates. The cohorts were then compared to evaluate the hazard ratios (HR) of receiving a new DR diagnosis, pars plana vitrectomy, panretinal photocoagulation, vitreous haemorrhage, proliferative diabetic retinopathy, diabetic macular oedema (DMO), and traction retinal detachment. The database contained 1,126,231 eligible patients (mean age: 60.8 [14.2] years; 46.0% female). Among patients without prior DR, low HDL (HR = 0.94, CI = 0.90-0.98), total cholesterol (HR = 0.88, CI = 0.85-0.91), and high triglyceride (HR = 0.91, CI = 0.86-0.97) levels were associated with a decreased risk of receiving a DR diagnosis. Among patients with preexisting DR, high LDL levels was associated with an increased risk of DMO (HR = 1.42, CI = 1.15-1.75), whereas low HDL levels was associated with a marginally decreased risk (HR = 0.92, CI = 0.85-0.99). Elevated levels of markers of dyslipidaemia are inversely associated with the risk of receiving a DR diagnosis, but this relationship is blunted after the onset of DR.

Macular Holes in Tractional Retinal Detachments Secondary to Diabetic Retinopathy

Purpose: To characterize the visual outcomes and rate of macular hole (MH) closure with tractional retinal detachment (TRD) and proliferative diabetic retinopathy (PDR). Methods: Visit data of patients who had pars plana vitrectomy were retrospectively reviewed; patient demographics, other procedure(s), the MH closure rate, and visual outcomes were also collected. Paired t, Fisher exact, and Mann-Whitney U tests were performed. Results: Ten patients (10 eyes) developed a TRD MH; 3 distinct MH presentations were identified. At the 3-month follow-up, 90% of MHs remained closed without the need for further reoperation (n = 6, type 1 closure; n = 3, type 2 closure). All MHs were closed 12 months after the initial surgery, with 1 eye requiring a single reoperation. The mean visual acuity (VA) at baseline and at 12 months was 20/235 and 20/138, respectively. Conclusions: MHs in the setting of fibrovascular proliferation resulting from PDR present with varied morphology. There is a high rate of MH closure and a trend toward improved VA.

Retinal detachment.

Retinal detachment (RD) occurs when the neurosensory retina, the neurovascular tissue responsible for phototransduction, is separated from the underlying retinal pigment epithelium (RPE). Given the importance of the RPE for optimal retinal function, RD invariably leads to decreased vision. There are three main types of RD: rhegmatogenous, tractional and exudative (also termed serous) RD. In rhegmatogenous RD, one or more retinal breaks enable vitreous fluid to enter the subretinal space and separate the neurosensory retina from the RPE. In tractional RD, preretinal, intraretinal or subretinal membranes contract and exert tangential forces and elevate the retina from the underlying RPE. Finally, in exudative RD, an underlying inflammatory condition, vascular abnormality or the presence of a tumour causes exudative fluid to accumulate in the subretinal space, exceeding the osmotic pump function of the RPE. The surgical management of RD usually involves pars plana vitrectomy, scleral buckling or pneumatic retinopexy. The approach taken often depends on patient characteristics as well as on practitioner experience and clinical judgement. Advances in surgical technology and continued innovation have improved outcomes for many patients. However, even if retinal re-attachment is achieved, some patients still experience decreased vision or other visual symptoms, such as metamorphopsia, that diminish their quality of life. Continued research in the areas of neuroprotection and retinal biology as well as continued surgical innovation are necessary to enhance therapeutic options and outcomes for these patients.

Chorioretinal Anastomosis and Retinal Detachment with Laser Photocoagulation Treated Incontinentia Pigmenti.

To describe a case of incontinentia pigmenti in which chorioretinal anastomosis occurred after laser photocoagulation, which was ultimately complicated by tractional and rhegmatogenous detachment. Observational case report. A 2-month-old was referred to ophthalmology for a rash characteristic of incontinentia pigmenti due to concern for ocular involvement and was found to have peripheral avascular retina with early neovascularization. Following several rounds of panretinal photocoagulation, a chorioretinal anastomosis was noted on follow up fluorescein angiography in the left eye. Subsequently, a tractional retinal detachment formed and was treated initially with a lens sparing pars plana vitrectomy, endolaser, and scleral buckle. Despite treatment, it progressed to a combined tractional/rhegmatogenous detachment and was deemed inoperable. Chorioretinal anastomosis is a rare complication of laser photocoagulation.

Bilateral tractional retinal detachment in hemoglobin SC disease patient

Bilateral tractional retinal detachment in hemoglobin SC disease patient

Spontaneous resolution of a diabetic traction retinal detachment

Spontaneous resolution of a diabetic traction retinal detachment

Pars Plana Vitrectomy for Proliferative Diabetic Retinopathy With and Without Internal Limiting Membrane Peeling: A Case Series

Introduction : Proliferative Diabetic Retinopathy (PDR) is a potentially blinding complication of diabetes mellitus, one of them because of tractional retinal detachment. Pars Plana Vitrectomy (PPV) is performed to treat it and in recent years internal limiting membrane (ILM) peeling has been employed as an additional treatment for patient with PDR.&#x0D; Case Illustration : Two patient, patient 1 (male, 64 years old) was diagnosed with right eye vitreous hemorrhage due to high-risk PDR and left eye vitreous hemorrhage due to early PDR + DME, and patient 2 (female, 58 years old) was diagnosed with right and left eye PDR + ERM + senile immature cataract. Both patients underwent PPV + membrane peeling + endolaser for both eyes, and additional ILM peeling on their left eye. The visual acuity 1 month after surgery without ILM peeling on right eye was improved to 6/30 and 6/18, and with ILM peeling on left eye was improved to 6/30 for both patients.&#x0D; Discussion : Removal of the ERM either with or without ILM peeling can significantly improve vision. However, many other comparison studies found no functional difference between both groups. In addition, one study found ILM removal was correlated with worse visual outcome. In this study, visual acuity 1 month after surgery in both with and without ILM peeling was improved compared with pre- operative.&#x0D; Conclusion : Although there are still pros and cons, PPV with additional ILM peeling gives results as good as PPV without ILM peeling for patient with PDR.

Incidence of Postoperative Epiretinal Membrane Development Following 23-Gauge Pars Plana Vitrectomy for Complex Diabetic Tractional Retinal Detachment: A Comparative Study of Silicone Oil and Balanced Salt Solution Tamponade

BACKGROUND: Tractional retinal detachment (TRD) poses a significant threat to vision in diabetic patients, necessitating surgical intervention. However, the choice of tamponade agent (silicone oil vs. balanced salt solution [BSS]) and the presence of incomplete hemostasis during surgery can influence postoperative complications, specifically the development of epiretinal membranes (ERMs). METHODS: This prospective study involved 235 patients undergoing 23-Gauge pars plana vitrectomy for diabetic TRD with incomplete hemostasis. Patients were categorized into two groups based on tamponade agent used. ERM development was assessed clinically and through optical coherence tomography (OCT). RESULTS: Among the cases with incomplete hemostasis and residual preretinal hemorrhage, 71.80% of those in the silicone oil group developed ERMs, in contrast to 11.76% in the BSS. Notably, 46.2% of silicone oil cases with ERMs required reoperation, whereas 47.4% remained ERM-free. DISCUSSION: The choice of tamponade agent was a crucial determinant in ERM development, with silicone oil exhibiting a significantly higher incidence. Moreover, silicone oil cases with macular tractional effects had a substantial proportion of ERMs necessitating reoperation. These findings underscore the importance of vigilant postoperative monitoring. CONCLUSION: In cases involving incomplete hemostasis during vitrectomy for diabetic TRD, the use of silicone oil as a tamponade agent is associated with a substantially increased risk of postoperative ERM development. Clinically, this highlights the need for meticulous patient management. Further research is warranted to validate these results and explore long-term outcomes.

Аnalysis of clinical cases of diabetic retinopathy progression in pregnant women with type 1 diabetes

Аnalysis of clinical cases of diabetic retinopathy progression in pregnant women with type 1 diabetes