糖尿病视网膜病变的白内障手术及视网膜光凝时机探讨

目的 观察糖尿病视网膜病变患者早期行白内障人工晶状体植入术后视网膜病变的发展情况,以及氩激光光凝治疗糖尿病视网膜病变(DR)的远期效果,探讨该类患者白内障手术和视网膜光凝治疗的时机,分析其联合治疗的效果.方法 对合并白内障的糖尿病视网膜病变患者,符合纳入标准的病人共67例,以未手术眼作为对照.白内障术后经眼底荧光造影(FFA)随访观察,随访时间1年.当检查具有光凝指征时,均行氩激光视网膜光凝.对比观察手术眼和对照眼视网膜光凝前后的视网膜病变发展程度.结果 白内障术后手术眼和对照眼经FFA随访观察需行视网膜光凝分别为26只眼(41.94%)及24只眼(38.71%),其视网膜病变发展程度基本一致;白内障人工晶状体植人手术后及时光凝的病人,DR病情稳定或减慢发展,黄斑水肿消退或减轻,视力稳定,手术眼比未手术眼获得更充分的视网膜光凝及稳定的视力和视觉质量,2例患者拒绝接受视网膜光凝治疗,晚期发生新生血管性青光眼及玻璃体出血.结论 完美的无并发症的白内障人工晶状体植入手术不会加速DR的发展;及时充分地视网膜光凝治疗,将减缓DR的发展及减少其并发症(新生血管性青光眼、玻璃体出血)的发生,稳定视力.     

白内障术后糖尿病视网膜病变的光凝治疗

观察白内障术后糖尿病视网膜病变的光凝治疗效果及光凝后的远期复明效果 ,探讨光凝治疗的时机 ,影响光凝的因素。方法 :对我院 5年来行白内障手术的伴有糖尿病视网膜病变且具有光凝指征的病人 ,将其分为两组 ,白内障术后行光凝治疗组5 3例 ,未行光凝治疗组 45例。结果 :白内障术后早期光凝治疗的病人 ,糖尿病视网膜病变稳定 ,黄斑水肿消褪或减轻 ,视力保持稳定。未行光凝治疗的病人 ,视网膜病变加重 ,视力下降甚至失明。结论 :伴有糖尿病视网膜病变的白内障病人行白内障手术后 ,如有光凝指征 ,应尽早行光凝治疗。这对于控制或延缓糖尿病视网膜病变的进展 ,稳定病人视力 ,提高这些白内障病人的远期复明效果 ,有重要意义。     

白内障人工晶体植入术后的糖尿病视网膜病变氩激光治疗

目的观察白内障人工晶体植入术后糖尿病视网膜病变(DR)的氩激光光凝治疗效果及光凝后的远期效果,探讨光凝治疗的时机及影响光凝的因素。方法将最近三年我院行白内障人工晶体植入手术伴有糖尿病视网膜病变,经FFA检查具有光凝指征的病人分成二组,治疗组白内障术后行网膜氩激光光凝30例;对照组白内障人工晶体植入术后拒绝氩激光光凝26例。结果白内障人工晶体(IOL)植入术后及时光凝的病人,DR病情稳定或减慢发展,黄斑水肿消退或减轻,视力稳定。未行氩激光光凝治疗的病人,DR加重,部分出现新生血管性青光眼,视力下降甚至失明。结论白内障人工晶体植入术后伴有DR的病人及时检查FFA,如发现光凝指征应及时行氩激光光凝治疗,将减少其并发症(新生血管性青光眼、玻璃体出血)的发生,稳定视力。     

玻璃体切除术联合晶状体手术治疗增生性糖尿病性视网膜病变

目的:评价玻璃体手术联合晶状体手术治疗增生性糖尿病性视网膜病变的临床效果。方法:对68例68眼增生性糖尿病性视网膜病变合并白内障患者行玻璃体切除术联合晶状体超声乳化吸出术治疗,其中35例Ⅰ期植入折叠型后房型人工晶状体。结果:术后43例(63.2%)患者视力提高,术中无严重并发症发生,术后7例(10.3%)角膜上皮愈合延迟,5例(7.4%)发生新生血管性青光眼,6例(8.8%)发生复发性玻璃体积血,4例(5.9%)发生复发性视网膜脱离,4例(5.9%)发生后发性白内障。结论:玻璃体切除术联合晶状体超声乳化吸出术治疗增生性糖尿病性视网膜病变合并白内障,可以改善视功能。     

氩激光视网膜光凝治疗糖尿病性视网膜病变

目的观察糖尿病性视网膜病变的光凝治疗效果。方法对136例(261只眼)糖尿病性视网膜病变患者,根据病变的程度行氩激光视网膜光凝治疗,并随访1年,观察光凝治疗变后患者的视力、眼底及荧光血管造影的变化,并进行分析和比较。结果在136例(261只眼)糖尿病性视网膜病变中,有效226只眼,总有效率 86．5％,其中增生前期糖尿病视网膜病变64只眼,有效60只眼,有效率93．7％;增生期糖尿病视网膜病变197只眼,有效眼166,有效率84．2％％。经统计学检验P<0．01,两者有显著差异。讨论对早期糖尿病性视网膜病变患者,如有光凝指征,应尽早行氩激光视网膜光凝治疗,这对于控制或延缓糖尿病性视网膜病变的进展,稳定患者视力有重要意义。     

白内障术后糖尿病视网膜病变的综合治疗

目的:观察激光光凝联合复方樟柳碱治疗白内障术后糖尿病视网膜病变(DR)的疗效。方法:对50例(76眼)白内障术后DR患者施行激光光凝同时予复方樟柳碱注射液颞浅动脉旁皮下注射,以视力和眼底改变为疗效判定指标。结果:白内障术后糖尿病视网膜病变稳定,黄斑水肿减轻或消退,视力稳定。结论:白内障术后DR患者具有光凝指征应尽早综合治疗,对于控制糖尿病视网膜病变进展,提高白内障远期复明效果有重要意义。     

白内障患者术前角膜内皮细胞分析

目的分析不同白内障患者术前角膜内皮情况,以评估角膜对手术的耐受程度。方法白内障198例（277只眼）,按伴有的眼病不同分为7个组。所有患者术前检测角膜内皮细胞密度、细胞平均面积、六角形细胞比例。采用SPSS16．0进行单因素方差分析。结果急性闭角型青光眼组和增生性糖尿病视网膜病变组与正常组（不伴有其他眼病的单纯老年性白内障）比较,二者角膜内皮细胞密度下降,细胞平均面积增大,差异有统计学意义（P〈0．05）。前者六角形细胞比例未见明显下降;后者六角形细胞比例下降。慢性闭角型青光眼组、非增生性糖尿病视网膜病变组、高度近视组、陈旧性葡萄炎组与正常组比较,三项指标差异均无统计学意义（P〉0．05）。结论急性闭角型青光眼、增生性糖尿病视网膜病变均可对角膜内皮产生影响;而慢性闭角型青光眼、非增生性糖尿病视网膜病变、高度近视、陈旧性葡萄炎对角膜内皮细胞形态没有明显影响。     

玻璃体视网膜手术联合眼内光凝治疗增生性糖尿病性视网膜病变

目的 对增生性糖尿病性视网膜病变的玻璃体切除手术的适应证、手术时间、手术结果进行探讨。方法 对42例(42只眼)增生性糖尿病性视网膜病变患者常规行巩膜环扎后，再行闭合式三切口玻璃体切除术，首先切除混浊的玻璃体，割断玻璃体内前后方向牵拉视网膜的纤维条索，切断视网膜前纤维桥带成小岛。最后争取彻底剥离视网膜前膜并切净。术中对32只眼行二级管眼内激光光凝。结果 42只眼经过3—10个月随访(平均11．3个月)，有24只眼增生性视网膜病变得到不同程度的视力改善，14只眼视力保持不变；4只眼视力下降；6只眼(14．3％)发生孔源性视网膜脱离；5只眼（11．9％)发生再出血；1只眼(2．3％)发生新生血管性青光眼。结论 正确把握糖尿病患者PDR玻璃体切除术的适应证、手术时机和手术技巧，才能降低糖尿病眼病的致盲率。同时玻璃体切割术中行眼内光凝是治疗PDR的必要手段。     

玻璃体手术前视网膜光凝对增生型糖尿病视网膜病变患者预后的影响

目的　分析玻璃体手术前视网膜光凝对增生型糖尿病视网膜病变患者预后的影响。方法　回顾性分析我院因增生型糖尿病视网膜病变行玻璃体手术患者125例（150眼）。根据术前是否行视网膜光凝分为光凝组（30眼）与非光凝组（120眼），术后随访6个月以上；比较手术情况及术后填充介质情况、术后视力提高率、手术时间等。结果　本研究150眼均顺利完成玻璃体手术。光凝组患者均无术后再出血发生，而非光凝组中4眼发生术后再出血，且均发生于术后8个月后。光凝组中15眼可见新生血管增生膜，其中11眼术中使用电凝止血；而非光凝组中80眼可见新生血管增生膜，其中70眼术中使用电凝止血；光凝组术中发现或形成视网膜裂孔9眼，视网膜脱离6眼，而非光凝组术中发现或形成视网膜裂孔28眼，视网膜脱离37眼。非光凝组患者硅油填充76眼（63.3%），光凝组患者硅油填充20眼（66.7%），两组间填充介质差异有统计学意义，非光凝组患者硅油填充率较高（P<0.05）。两组患者术后6个月视力大部分较术前有所提高，光凝组视力提高率为70％，非光凝组视力提高率为50％，两组间视力提高率差异有统计学意义，光凝组视力提高居多（P<0.05）。光凝组手术时间为（85.83±20.80）min，非光凝组手术时间为（103.53±31.80）min，光凝组手术时间较非光凝组手术时间明显缩短（P<0.05）。结论　糖尿病视网膜病变玻璃体手术前视网膜光凝对预后有积极的影响，可降低玻璃体手术后再出血的发生。     

糖尿病视网膜病变全视网膜光凝后的视力损害

全视网膜光凝(PRP)是治疗严重的糖尿病视网膜病变的重要方法,但PRP可引起黄斑水肿而导致视力下降。作者通过研究证明黄斑中心凹厚度与视力预后相关。64例(64眼)非增生期或增生早期糖尿病视网膜病变患者参与了研究,患者均未曾对眼部并发症进行治疗,视力均≥1·0。所有患者进行了     

Anti-VEGF crunch syndrome in proliferative diabetic retinopathy: A review

Anti-vascular endothelial growth factor (anti-VEGF) crunch syndrome describes the progression to tractional retinal detachment following intravitreal anti-VEGF therapy in an eye with proliferative diabetic retinopathy . We reviewed the literature on the anti-VEGF crunch using the PubMed and Cochrane databases. Anti-VEGF crunch typically manifests as sudden vision loss in the affected eye between 1 and 6 weeks following intravitreal anti-VEGF injection, with a mean onset of 13 days. Risk factors for crunch development include the use of a higher anti-VEGF dose and increased severity of diabetic retinopathy with fibrosis. Our review found that intravitreal anti-VEGF, in particular bevacizumab, should be used with caution when treating patients with severe proliferative diabetic retinopathy and pre-existing intraocular fibrosis. In patients where anti-VEGF is used before a planned vitrectomy, we recommend close monitoring for crunch symptoms and proceeding promptly with surgery if there is new or progression of tractional retinal detachment. For eyes with minimal preexisting traction that develop crunch after anti-VEGF treatment, surgeons should proceed to vitrectomy within 7 days. The existing literature on the anti-VEGF crunch is limited by heterogeneity in the way crunch is documented and characterized and the presence of panretinal photocoagulation as a confounding factor. Because of these methodological flaws, the relative frequency of the anti-VEGF crunch cannot be accurately estimated.     

The long-term effects of laser photocoagulation treatment in patients with diabetic retinopathy: the early treatment diabetic retinopathy follow-up study

OBJECTIVES: To evaluate the long-term natural history and effects of laser photocoagulation treatment in patients with diabetic retinopathy. DESIGN: Follow-up study of the 214 surviving patients enrolled originally at the Johns Hopkins Clinical Center for the Early Treatment Diabetic Retinopathy Study (ETDRS), which was a clinical trial designed to evaluate the role of laser photocoagulation and aspirin treatment in patients with diabetic retinopathy. METHODS: Early Treatment Diabetic Retinopathy Study patients enrolled in the Johns Hopkins Clinical Center had complete eye examinations, including best-corrected visual acuity measurements, fundus photographs, and medical questionnaires throughout the 7-year study. They had the same examinations at the final long-term follow-up visit at the National Eye Institute, National Institutes of Health, 13 to 19.5 years after the initial laser photocoagulation (median, 16.7 years). MAIN OUTCOME MEASURES: The major outcomes were mortality and the rates of moderate and severe vision loss. The secondary outcomes were progression of diabetic retinopathy and need for other eye surgery. RESULTS: Of the 214 patients who were alive at the end of the original ETDRS in 1989, 130 (61%) were deceased at the time of the re-examination. Of the 84 who were alive, 71 (85%) were examined at their long-term follow-up visit at the National Institutes of Health. At the long-term follow-up examination, 42% had visual acuity of 20/20 or better, and 84% had visual acuity of 20/40 or better in the better eye. Compared with baseline, 20% of patients had moderate vision loss (loss of 3 lines or more vision) in the better eye at follow-up. Only one patient had visual acuity of 20/200 bilaterally. He had visual acuity loss secondary to age-related macular degeneration. No patient had severe vision loss (worse than 5/200). All the initially untreated eyes of patients who had severe nonproliferative diabetic retinopathy or worse by the time of the ETDRS closeout visit of the original study received scatter photocoagulation treatment. Focal photocoagulation was performed in 43% bilaterally and 22% unilaterally. Cataract surgery was performed in 31% of the patients, vitrectomy in 17%, and glaucoma surgery in one patient. CONCLUSIONS: As previously reported, the mortality rate of patients with diabetic retinopathy is much higher than that of the general population. For those who survived, aggressive follow-up, with treatment when indicated, seems to be associated with maintenance of good long-term visual acuity for most patients. The need for laser scatter photocoagulation with long-term follow-up seems to be high.     

Cryoapplication in diabetic retinopathy

Thirty-five patients with diabetic retinopathy were treated with cryoapplication. This was used as an alternative to Argon laser or Zenon photocoagulation because the media was opaque from vitreous hemorrhage or cataract. It was difficult or impossible to treat with photocoagulation.The clinical impression indicates that cryoapplication is effective, showing adequate pigmentation and chorioretinal scarring with regression of diabetic retinopathy changes. However patients with vitreo-retinal fibrosis became frequently worse weeks later. This is considered a contraindication.The use of cryoapplication in diabetic retinopathy is recommended in situations where the ocular media is not clear, such as vitreous hemorrhage and cataract. It can also be used if there is difficulty with laser photocoagulation following lens implantation.It may be valuable in some developing countries where photocoagulation is not available. Cryomachines are frequently used in eye camps. It is inexpensive and does not necessarily require electricity.     

Management of type 2 diabetics requiring panretinal photocoagulation and cataract surgery

PURPOSE: To evaluate the outcomes in patients with diabetic retinopathy and cataract who had panretinal photocoagulation (PRP) first and cataract surgery second in 1 eye and cataract surgery followed by PRP in the fellow eye. SETTING: Department of Ophthalmology, Saiseikai Kurihashi Hospital, Saitama, Japan. METHODS: Fifty-eight eyes of 29 patients with similar bilateral cataracts and severe nonproliferative or early proliferative diabetic retinopathy were randomly assigned for treatment with cataract surgery performed after PRP (PRP-first group) or before PRP (surgery-first group). Treatment was performed in the opposite order in the contralateral eye. The main outcome measure was best corrected visual acuity (BCVA) 12 months after surgery. The secondary outcome measures were the laser parameters, progression of retinopathy and macular edema, and aqueous flare intensity. RESULTS: The percentage of eyes with a BCVA of 20/40 or better was statistically significantly higher in the surgery-first group (96.6%) than in the PRP-first group (69.0%) (P = .012). The rate of the progression of macular edema was significantly decreased in the surgery-first group (P = .033). There was no significant difference between the 2 groups in the other outcome measures. CONCLUSION: Although the order in which PRP and cataract surgery were performed had no effect on postoperative retinopathy, the BCVA was better and the rate of the progression of macular edema was decreased in the surgery-first group.     

Diabetic macular edema and argon laser photocoagulation: a prospective randomized study

Loss of vision from diabetic retinopathy can result from complications of neovascular proliferation, or frequently, from macular edema secondary to background diabetic retinopathy. Although the benefits of photocoagulation for proliferative diabetic retinopathy have been clarified by the National Eye Institute's collaborative diabetic retinopathy study, those for background diabetic retinopathy with macular edema remain unclear. Several articles have described the visual benefits and reduction of edema following photocoagulation of eyes with background diabetic retinopathy and macular edema, but only Patz's study was prospectively designed utilizing a random assignment of laser treatment for one eye with the other eye remaining untreated. This article reports the two-year results of a similar prospective study in which one eye in each of 39 patients with symmetrical macular edema secondary to background diabetic retinopathy was randomly selected to receive argon laser photocoagulation, while the fellow eye remained untreated.     

Effect of cataract surgery on the progression of diabetic retinopathy

PURPOSE: To study the effect of cataract surgery and other factors on the progression of diabetic retinopathy using the nonoperated contralateral eye as a control. SETTING: Department of Ophthalmology, Catholic University Medical College, Uijongbu St. Mary's Hospital, Seoul, Korea. METHODS: Monocular cataract surgery was performed in 75 patients who had the same degree of retinopathy or no retinopathy in both eyes preoperatively. Patients were assigned to 1 of 2 groups as follows: Group A, progression of retinopathy in the operated eye caused by cataract surgery; Group B, no progression of retinopathy bilaterally, comparable level of progression in both eyes, or more progression of retinopathy in the nonoperated eye than in the operated eye. The differences between the 2 groups in age, duration of and treatment methods for diabetes, renal function, and presence of preoperative macular edema were compared. The 1-year follow-up included evaluation of the progression of retinopathy. RESULTS: Surgery caused the retinopathy to progress in 23 patients (30.6%, Group A); 52 patients (69.4%, Group B) had no progression of retinopathy or a comparable level of retinopathy postoperatively. The operated eye had more progression of retinopathy than the nonoperated contralateral eye (P <.05). There was no significant difference between the 2 groups in age, diabetes duration, surgical method, or hypertension. Preoperative macular edema and poor renal function significantly affected the progression of diabetic retinopathy after cataract surgery (P <.05). CONCLUSIONS: Diabetic retinopathy progressed after cataract surgery. The presence of preoperative macular edema and poor renal function increased the progression of retinopathy postoperatively.     

A prospective, case controlled study of the natural history of diabetic retinopathy and maculopathy after uncomplicated phacoemulsification cataract surgery in patients with type 2 diabetes

AIM: To determine if uncomplicated phacoemulsification cataract surgery is associated with an accelerated rate of progression of diabetic retinopathy or maculopathy postoperatively. METHODS: A prospective trial of 50 type 2 diabetics undergoing monocular phacoemulsification cataract surgery by a single consultant surgeon. The grade of diabetic retinopathy and diabetic maculopathy in the operated and non-operated fellow eye was assessed preoperatively and for 12 months postoperatively. RESULTS: Overall, retinopathy progression was observed in 11 patients. In seven the retinopathy progressed in both eyes, in three it progressed in the operated eye alone, and in one it progressed in the fellow eye alone. Macular oedema was observed in 13 eyes postoperatively. Four had transient pseudophakic cystoid macular oedema and nine true diabetic maculopathy. Where maculopathy progressed it did so symmetrically in five patients, it progressed in the operated eye alone in four patients, and the fellow eye alone in two patients. There was no significant difference in the number of operated and fellow eyes whose retinopathy or maculopathy progressed postoperatively. In both the operated (OE) and non-operated (NoE) eyes retinopathy progression was associated with a higher mean HbA(1)C (OE p=0.003; NoE p=0.001) and insulin treatment (OE p=0.008, NoE p=0.04). CONCLUSION: Uncomplicated phacoemulsification cataract surgery does not cause acceleration of diabetic retinopathy postoperatively and any progression that is observed probably represents the natural history of the disease. Although macular oedema is common after cataract surgery it may follow a benign course and in many patients the development of clinically significant macular oedema postoperatively probably represents natural disease progression rather than being a direct effect of surgery.     

Fulminant proliferative diabetic retinopathy in the non-photocoagulated eye following acute renal failure

Management of diabetic retinopathy should follow more strict and aggressive rules in patients at risk for severe acute renal impairment. Such patients should be identified and possibly prophylactically laser treated to avoid the severe consequences demonstrated in this case report. A 34-year-old type 2 diabetes patient with a stabilized diabetic retinopathy developed acute and severe retinal decompensation within weeks after acute renal failure complicated his chronic stable renal impairment. Fluorescein angiographic and optical coherence tomographic illustrations of the rapid evolution of the retinal condition are presented. The patient had previously been treated with panretinal photocoagulation in his left eye. After 8 years of regular 6-monthly checked stability, he developed rapid-onset proliferative diabetic retinopathy and macular edema in his right eye within 3 months of his last ocular check-up. Fluorescein angiography showed neovessels and major ischemic areas. Emergency panretinal photocoagulation and a sub-Tenon’s injection were necessary to achieve control of the situation with regression of neovessels and complete regression of macular edema. This case shows that it is imperative for nephrologists to be well informed about a patient’s ocular situation in order to give timely information to the ophthalmologist who can intervene to protect the retina in case of renal failure. On the other hand, the ophthalmologist should be familiar with the renal function of his patient with renal impairment so that he can decide to perform prophylactic retinal panphotocoagulation that should be imperatively considered even without strict indications in patients with renal impairment at risk for further deterioration of renal function, in order to prevent such explosive ischemic and proliferative retinopathy putting vision at risk.     

Proliferative diabetic retinopathy: vitreo-retinal complications are often related to insufficient retinal photocoagulation

INTRODUCTION: Panretinal photocoagulation proved to be effective in preventing complications related to vasoproliferative diabetic retinopathy. Surgery is most often a last resort in cases of recurrent or persistent vitreous hemorrhage or retinal detachment. The aim of our study is to point out that eyes requiring surgery for complications related to vasoproliferative diabetic retinopathy are often insufficiently photocoagulated. PATIENTS AND METHODS: Retrospective analysis of operating protocols and surgical results for a series of 39 eyes of 36 patients with complications of vasoproliferative diabetic retinopathy. RESULTS: The mean age at the intervention was 57 years. Eighty-five percent of the eyes had a vitreous hemorrhage, 17% a retinal detachment. Eighty-five percent of the eyes had undergone a partial retinal photocoagulation before surgery. All eyes underwent a vitrectomy with segmentation of fibrovascular membranes. In 85% of the eyes studied, endolaser photocoagulation was necessary, sometimes even in the mid-periphery. After 39+/-26 months of postoperative follow-up, 97% of eyes showed improvement of the anatomical state of the retina and improvement or stabilization of visual acuity. CONCLUSION: Our results confirm the benefit of vitreoretinal surgery in complications related to vasoproliferative diabetic retinopathy. Moreover, it should be emphasized that complications requiring surgery often result from incomplete preoperative photocoagulation. To be effective, photocoagulation has to destroy more than 35% and up to 50% of photoreceptors. An intraoperative laser extension can reduce the risk of regrowth of fibrovascular membranes.     

白内障摘除人工晶体植入术后糖尿病性视网膜病变进展的观察

为观察白内障囊外摘除术后糖尿病性视网膜病变的进展，我们对７０例糖尿病患者中的７０眼行白内障囊外摘除人工晶体植入术。术后对术眼及对侧非手术眼进行了观察比较。发现术眼中３８眼（５４．３％）非手术眼中（１５．７％）出现视网膜病变进展。术眼中６６眼（９４％）视力优于术前。但视力结果取决于视网膜病变特别是黄斑病变程度。说明白内障手术加剧糖尿病性视网膜病变，但非禁忌证。早期视网膜光凝可防止病变进展，有助于稳定视力。