Pars plana vitrectomy with internal limiting membrane peeling for diabetic macular edema

PURPOSE: To evaluate anatomic and visual acuity (VA) results of pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling for diffuse diabetic macular edema (DME), and to review the literature on the topic. METHODS: Retrospective noncomparative case series of patients who underwent PPV with ILM peeling for diffuse DME between January 1, 2000, and December 1, 2005, performed by three surgeons at Bascom Palmer Eye Institute. Main outcome measures included pre- and postoperative optical coherence tomography (OCT) and visual acuity. Mean follow-up period was 8 months (range, 43 days-2 years). RESULTS: Twenty-four eyes of 23 patients meeting the criteria were evaluated. Duration of DME ranged from 1 to 93 months. Mean preoperative logMAR vision was 0.782 (range, 0.30-1.82). Mean logMAR visual acuity at final follow-up was 0.771 (range, 0.10-2.00). At last follow-up, 25% of eyes had > or =2 line increase in VA from baseline, 54% of eyes had no improvement in VA, and 21% of eyes had > or =2 line decrease in VA. Of 9 eyes with pre- and postoperative OCT, there was an overall reduction in central macular thickness of 141 microm at postoperative month 3 and 120 microm at last follow-up. Postoperative complications included progression of cataract in 6 (60%) of 10 phakic eyes, postoperative intraocular pressure > or =30 mmHg in 6 (24%) eyes, and postoperative vitreous hemorrhage in 2 (8%) eyes. CONCLUSIONS: Pars plana vitrectomy with ILM peeling was associated with a reduction in DME when measured by OCT in the majority of eyes, but visual acuity outcomes showed minimal improvement compared to baseline. These results suggest the efficacy of PPV with ILM peeling for eyes with DME has not been well established and should be reserved for therapy with selected cases.     

Pars plana vitrectomy and removal of the internal limiting membrane in diabetic macular edema unresponsive to grid laser photocoagulation

PURPOSE: To evaluate the effectiveness of pars plana vitrectomy (PPV) with removal of the internal limiting membrane (ILM) in diabetic patients with macular edema unresponsive to grid laser photocoagulation. METHODS: In this randomized controlled study, 20 eyes of 10 patients with diabetic macular edema unresponsive to grid laser photocoagulation were evaluated. PPV with ILM removal was performed randomly in one eye each of 10 patients and taken as the study group; the untreated fellow eyes were taken as the control group. Main outcome measures were foveal thickness changes measured with optical coherence tomography and preoperative and post-operative visual acuity. Mann-Whitney U, Wilcoxon, and chi-square tests were used in statistical analysis. RESULTS: The mean age of the patients was 61.5+/-6 years (range 51 to 71). All patients were followed up for 12 months. In the study group, mean foveal thickness was 391.3+/-91.6 microm preoperatively and 225.5+/-49.4 microm postoperatively (p=0.009). In the control group, mean foveal thickness was 356.2+/-140 microm at baseline and 318.4+/-111.1 microm at 12-month follow-up (p=0.138). Mean decrease in foveal thickness was 165.8+/-114.8 microm in the study group and 37.8+/-71.2 microm in the control group (p=0.016). In the study group, best-corrected log-MAR visual acuity was 0.71+/-0.43 preoperatively and 0.54+/-0.45 postoperatively (p=0.125). In the control group, best-corrected logMAR visual acuity was 0.43+/-0.44 at baseline and 0.59+/-0.55 at 12-month follow-up (p=0.235). In the study group, visual acuity improved by two or more lines in 4 eyes (40%) and remained stable in 6 eyes (60%). In the control group, visual acuity improved by two or more lines in 1 eye (10%) and decreased by two or more lines in 3 eyes (30%). CONCLUSIONS: PPV with ILM removal appears to be an effective procedure for reducing diabetic macular edema unresponsive to grid laser photocoagulation. A further study with a large number of patients is required to assess the effectiveness and safety of this procedure.     

Pars plana vitrectomy with internal limiting membrane removal for macular hole associated with proliferative diabetic retinopathy

Background We describe the outcome of vitreous surgery in three eyes of three patients with macular hole associated with proliferative diabetic retinopathy (PDR) in the absence of fibrovascular proliferation, a combination of conditions where efficacy is incompletely known.Methods The patients, all male were 62, 65, and 66 years old. Panretinal photocoagulation had been performed preoperatively in all, and one eye had undergone vitreous surgery. No fibrovascular tissue causing macular traction was observed in any case. Fluorescein angiography and optical coherence tomography (OCT) demonstrated persistent diabetic macular edema surrounding the hole. Affected eyes were treated with vitrectomy including internal limiting membrane (ILM) peeling; 20% sulfur hexafluoride gas (SF₆) was introduced for tamponade.Results Anatomical closure of the macular hole as well as resolution of macular edema was achieved in all cases, and vision improved considerably by more than two Snellen lines.Conclusions Vitreous surgery with ILM peeling was effective for macular hole associated with PDR, attaining not only macular hole closure but also resolution of persistent diabetic macular edema.No author has a financial or proprietary interest in any material or method mentioned     

Long-term outcomes of pars plana vitrectomy with internal limiting membrane removal in diabetic macular edema

PURPOSE: To report the long-term visual results and anatomical outcome as assessed by optical coherence tomography (OCT) after pars plana vitrectomy (PPV) with removal of the internal limiting membrane (ILM) in diabetic macular edema (DME). METHODS: Medical records of 27 eyes of 27 patients who underwent PPV with ILM removal for DME attributable to diffuse leakage were reviewed. This retrospective study included eyes that underwent PPV with ILM removal at our institution with preoperative and postoperative OCT assessment of DME. None of the eyes had OCT evidence of anteroposterior vitreomacular traction. Main outcome measures were foveal thickness and visual acuity changes. RESULTS: Foveal thickness decreased by at least 20% in 22 eyes (81.4%) and increased by at least 20% in 3 eyes (11.1%) with PPV and ILM removal (mean follow-up +/- SD, 27.6 +/- 7.2 months; range, 12-38 months). Mean foveal thickness decrease +/- SD was 178 +/- 164 microm (43.6%), with a mean preoperative foveal thickness +/- SD of 408 +/- 121 microm compared with a mean postoperative foveal thickness +/- SD of 230 +/- 74 microm (P < 0.001). Recurrence of DME was observed at postoperative month 24 in 2 eyes and postoperative month 30 in 1 eye. Visual acuity improved by > or =2 lines in 10 eyes (37%) and decreased by > or =2 lines in 3 eyes (11.1%). Mean best-corrected logMAR (logarithm of the minimum angle of resolution) visual acuity +/- SD was 0.75 +/- 0.35 preoperatively and 0.63 +/- 0.33 postoperatively (P = 0.033). CONCLUSION: PPV with ILM removal appears to be effective in reducing DME and improving visual acuity, and its effectiveness is maintained in the long term. Recurrence of DME may be observed in the late postoperative period.     

Pars plana vitrectomy in diabetic macular edema

Purpose: To ascertain the association between the improvement of diabetic macular edema and increased visual acuity after pars plana vitrectomy. Methods: From January 1994 to December 1996 we prospectively studied 18 patients (18 eyes, 7 women and 11 men, mean age 52 years, range 37–68) with type II diabetes and clinically significant macular edema. One group was composed of 9 patients presenting diffuse macular edema (DME); a second group with 9 patients presented cystoid macular edema (CME). All patients underwent pars plana vitrectomy. Results: Preoperative Snellen visual acuity was 20/143 in DME and 20/441 in CME. In both groups vision increased to 20/136 and 20/205, respectively, postoperatively. For the DME this difference was statistically significant (p<0.05) at 1 month after the surgery, but vision decreased again after 10 months reaching preoperative values. Conclusions: Our results suggest that pars plana vitrectomy for diabetic macular edema may increase visual acuity in diffuse macular edema, although this increase is only short lived. This revised version was published online in July 2006 with corrections to the Cover Date.     

Pars plana vitrectomy and removal of the internal limiting membrane in the treatment of chronic macular oedema

Background To evaluate the results of pars plana vitrectomy with peeling of the internal limiting membrane (ILM) in eyes with chronic macular oedema.Methods PPV with indocyanine green (ICG) assisted peeling of the ILM was performed in 33 eyes with diabetic (21 eyes) or non-diabetic (12 eyes) macular oedema. Postoperatively, resolution of macular oedema, improvement of visual acuity (VA) and complications were documented. The peeled membranes were submitted for light and transmission electron microscopic evaluation.Results The mean follow-up time was 12.2 months. The macular oedema decreased or was resolved in 17 (81%) eyes in the diabetic group and in 11 (92%) eyes in the non-diabetic group. VA improved by at least 2 lines in 11 (52%) eyes in the diabetic group and in 7 (58%) eyes in the non-diabetic group. The difference between visual acuity improvements of the two groups was not statistically significant (P>0.05). However, in the diabetic group the difference of visual improvement between cystoid and diffuse type of macular oedema eyes was statistically significant (14% versus 71%, P=0.02). Light and transmission electron microscopy showed the presence of ILM in all specimens. During the follow-up period no recurrence of macular oedema or epiretinal membrane formation was observed.Conclusion Pars plana vitrectomy with peeling of the ILM and epiretinal membrane leads to the resolution of macular oedema in the majority of eyes. This however, is not always associated with VA improvement. In diabetic eyes, cystoid type of macular oedema appears to be a poor prognostic factor for improved VA.     

玻璃体切割联合内界膜剥离治疗RVO继发黄斑水肿

目的：评估玻璃体切割联合内界膜剥离治疗视网膜静脉阻塞（retinal vein occlusion, RVO）继发黄斑水肿的治疗效果。 方法：对12例视网膜中央或分支静脉阻塞的患者行玻璃体切割联合内界膜剥离,记录术前术后最佳矫正视力（BCVA）及黄斑中心凹厚度。结果：术前平均黄斑中心凹厚度563.9±90.0μm, 术后2mo黄斑中心凹的平均厚度为361±61.1μm,术后黄斑厚度较术前明显降低（P=0.001）。所有CRVO的BCVA均有所提高,而8例BCVO只有4例术后视力得到提高。术前平均标准对数视力表的BCVA为1.23±0.29,术后为1.06±0.49,术后与术前相比无统计学意义（P=0.09）。结论：玻璃体切割联合内界膜剥离可显著改善RVO继发的黄斑水肿,但术后视力提高不明显。     

Pars plana vitrectomy with and without peeling of the inner limiting membrane for diabetic macular edema

PURPOSE: A prospective, comparative, nonrandomized study to evaluate the efficacy of pars plana vitrectomy (PPV) with and without inner limiting membrane (ILM) peeling for persistent diffuse clinically significant macular edema. METHODS: Eighteen patients with persistent diffuse clinically significant macular edema despite laser photocoagulation were recruited for the study. Clinical assessment included determination of best-corrected visual acuity, fundus fluorescein angiography, optical coherence tomography, and perifoveal cone function testing. Eight patients underwent PPV with elevation and removal of the posterior hyaloid alone, and 10 patients underwent vitrectomy and ILM peeling. The follow-up was 12 months. RESULTS: Patients with ILM peeling had improvement in foveal thickness (P = 0.07) and significant improvement in the macular volume (P = 0.039) 12 months after surgery but did not have significant improvement in Early Treatment Diabetic Retinopathy Study vision or perifoveal cone function. There was no significant difference in outcome parameters between the no peeling group and the ILM peeling group. CONCLUSIONS: In this prospective, comparative study of PPV with and without ILM peeling for diffuse clinically significant macular edema, structural improvement was seen but with limited visual improvement after ILM peeling.     

Modified grid laser photocoagulation versus pars plana vitrectomy with internal limiting membrane removal in diabetic macular edema

PURPOSE: To compare the effectiveness of pars plana vitrectomy (PPV) and removal of the internal limiting membrane (ILM) with modified grid laser photocoagulation in diabetic macular edema. DESIGN: Randomized, comparative, interventional study. METHODS: In this prospective study, 24 eyes of 12 patients with bilateral diabetic macular edema were evaluated. PPV with removal of the ILM was performed at random in one eye of 12 patients (ILM group), and a single session of modified grid laser photocoagulation was performed in the fellow eyes (grid group). Main outcome measures were the foveal thickness measured with optical coherence tomography, preoperative, and postoperative visual acuities. Mann-Whitney U and Wilcoxon tests were used in statistical analysis. RESULTS: All patients were followed up for 6 months. In the ILM group, mean foveal thickness was 439.2 +/- 106.5 microm preoperatively and 219.8 +/- 63.2 mum postoperatively (P = .002). In the grid group, mean foveal thickness was 407 +/- 100.2 microm preoperatively and 378.5 +/- 141.6 microm postoperatively (P = .433). A mean decrease in foveal thickness was found to be 219.4 +/- 127.6 microm in the ILM group and 28.5 +/- 90.5 microm in the grid group (P = .001). In the ILM group, best-corrected logMAR visual acuity was 0.75 +/- 0.41 preoperatively and 0.53 +/- 0.41 postoperatively (P = .006). In the grid group, best-corrected logMAR visual acuity was 0.59 +/- 0.27 preoperatively and 0.49 +/- 0.27 postoperatively (P = .058). Visual acuity improved by 2 or more lines in six eyes (50%) in the ILM group and in three eyes (25%) in the grid group. Visual acuity remained stable in six eyes (50%) in the ILM group and in nine eyes (75%) in the grid group. CONCLUSIONS: PPV with ILM removal appears to be more effective than a single session of modified grid laser photocoagulation in the treatment of diabetic macular edema. Further studies with a large number of patients are required for a more reliable conclusion.     

Pars plana vitrectomy for refractory diabetic macular edema

Objective. The aim of this study is to describe the results of pars plana vitrectomy (PPV) for refractory diabetic macular edema (DME). Methods. Review of the relevant peer-reviewed scientific literature identified using Medline. Main Outcome Measures. The anatomical and functional outcome of surgery. Results. Vitrectomy with or without internal limiting membrane (ILM) peeling can be beneficial for the treatment of DME that is resistant to laser photocoagulation or sub-Tenon’s steroid injection. Visual improvement has been reported in ~40–90% of patients, with ~85–100% experiencing either improvement or stabilization of vision. Retinal edema decreases or resolves in ~70–100% of patients. Complications range in severity with ~5–20% of patients developing peripheral retinal breaks, ~1–2% developing retinal detachment, ~2% developing macular hole, and ~10–60% developing cataract. Severe complications such as rubeosis iridis and the fibrinoid syndrome have also been reported. Conclusion. Pars plana vitrectomy can be an effective treatment for diabetic macular edema refractory to laser therapy and/or sub-Tenon’s capsule steroid injection.     

Pars plana vitrectomy for refractory diabetic macular edema

OBJECTIVE: The aim of this study is to describe the results of pars plana vitrectomy (PPV) for refractory diabetic macular edema (DME). METHODS: Review of the relevant peer-reviewed scientific literature identified using Medline. MAIN OUTCOME MEASURES: The anatomical and functional outcome of surgery. RESULTS: Vitrectomy with or without internal limiting membrane (ILM) peeling can be beneficial for the treatment of DME that is resistant to laser photocoagulation or sub-Tenon's steroid injection. Visual improvement has been reported in approximately 40-90% of patients, with approximately 85-100% experiencing either improvement or stabilization of vision. Retinal edema decreases or resolves in approximately 70-100% of patients. Complications range in severity with approximately 5-20% of patients developing peripheral retinal breaks, approximately 1-2% developing retinal detachment, approximately 2% developing macular hole, and approximately 10-60% developing cataract. Severe complications such as rubeosis iridis and the fibrinoid syndrome have also been reported. CONCLUSION: Pars plana vitrectomy can be an effective treatment for diabetic macular edema refractory to laser therapy and/or sub-Tenon's capsule steroid injection.     

Pars plana vitrectomy with internal limiting membranectomy for refractory diabetic macular edema without a taut posterior hyaloid

Background This is a retrospective study designed to investigate the effect of pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling on diabetic macular edema in eyes that do not have a taut hyaloid and have been refractory to standard laser treatment.Methods Review of 26 eyes of 20 patients consecutively were treated with PPV with ILM peel for refractory diabetic macular edema. Eyes were included if they had been unresponsive to conventional treatment defined as at least two focal laser applications by a retina specialist. Paired t-testing was performed to determine if a change in both optical coherence tomography (OCT)—measured retinal thickness and logarithm of the minimum angle of resolution (logMAR) visual acuity occurred prior to and following PPV with epiretinal membrane vitrectomy. In addition, we performed multivariate regression analysis to determine if any clinical variables predicted a change in visual acuity.Results The mean age in the sample was 65 years (range 29–81 years). The mean follow-up time was 242 days (range 35–939). Sixteen of the 26 eyes were phakic and the remaining ten were pseudophakic. There was a statistically significant improvement of mean visual acuity from a preoperative logMAR vision of 1.0 to a best postoperative vision of 0.75 (p=0.016, paired t-test). Thirteen (50%) of the 26 eyes gained at least two lines of best-corrected Snellen acuity, three (11.5%) had a decline of at least two lines, and ten (38.5%) showed stable visual acuity. Regression analysis demonstrated that baseline worse visual acuity was the only clinical variable that was associated with improvement in visual acuity (beta=0.602, p=0.016; R ²=28.7). Fourteen eyes had preoperative and postoperative OCT. Thirteen eyes (93%) had a significant decrease in foveal thickness; with an average preoperative thickness of 575 m compared to a postoperative average of 311 m (t=3.65, p=0.002). No surgical complications were observed during the follow-up period.Conclusions Surgery for refractory diabetic edema without a taut hyaloid is associated with a significant improvement in visual acuity and diminution of retinal thickness as measured by OCT. Further investigations are warranted to define the role of surgery in the management of persistent diabetic macular edema.The authors have full control of all primary data and agree to allow review of their data.     

玻璃体切割术联合内界膜剥离术治疗黄斑裂孔性视网膜脱落

目的：探究黄斑裂孔性视网膜脱落(macular hole retinal detachment,MHRD)患者应用玻璃体切割术(pars planavitrectomy,PPV)联合内界膜剥离术(internal limiting membrane peeling,ILMP)治疗的效果。

方法：选取我院在2013-12/2015-12期间收治的、符合纳入标准的MHRD患者78例83眼。根据患者是否应用PPV联合ILMP治疗,随机分为试验组(39例40眼)和对照组(39例43眼),对照组应用PPV治疗。观察两组治疗效果; 随访6mo后,比较两组患者视力改善情况以及手术前和手术后3、6mo的平均最佳矫正视力(best corrected visual acuity,BCVA); 并记录术后并发症发生情况。

结果：治疗效果：与对照组相比,试验组的视网膜复位率为92%(37/40),具有统计学差异(χ²=6.882,P=0.009); 视力改善情况：试验组的视力改善情况较对照组好,差异有统计学意义(χ²=14.216,P<0.001); 术后BCVA：试验组术后3、6mo的BCVA显著高于对照组,差异有统计学意义(t=7.119,P<0.001; t=10.573,P<0.001); 并发症：与对照组相比,试验组发生眼内压增高和视野缺损的情况较少,具有统计学差异(χ²=11.323,P=0.001; χ²=8.573, P=0.003); 晶状体混浊发生率无明显改变,但差异有统计学意义(χ²=1.835,P=0.176)。

结论：MHRD患者应用PPV联合ILMP术后恢复情况好,并发症发生率低,能更好地提高患者视网膜复位效果。     

Pars plana vitrectomy for diabetic macular edema. Internal limiting membrane delamination vs posterior hyaloid removal. A prospective randomized trial

Background  

Diabetes mellitus, as well as subsequent ocular complications such as cystoid macular edema (CME), are of fundametal socio-economic relevance. Therefore, we evaluated the influence of internal limiting membrane (ILM) removal on longterm morphological and functional outcome in patients with diabetes mellitus (DM) type 2 and chronic CME without evident vitreomacular traction.     

玻璃体切割术中联合内界膜剥除治疗糖尿病性黄斑水肿

目的探讨增生性糖尿病性视网膜病变（PDR）伴有黄斑水肿患者行玻璃体切割联合内界膜剥除术的疗效。方法选择19例（21只眼）严重PDR伴黄斑水肿患者行常规玻璃体切割联合黄斑区内界膜剥除术。结果本组19例（21只眼）均未发生手术并发症,视力提高15只眼,视力不变4只眼,下降2只眼。结论严重PDR伴黄斑水肿患者施行常规玻璃体切割术中联合内界膜剥除,有利于改善黄斑水肿,提高视力,疗效满意。