Coordination Skills during Vitrectomy in Treatment of Proliferative Diabetic Retinopathy

 Purpose: To discuss effective nursing and coordination skills for vitrectomy in the treatment of diabetic retinopathy. Methods: Fifty patients (51 eyes) with diabetic retinopathy required vitrectomy were enrolled in this study. Individual nursing service was delivered by strengthening preoperative preparation, providing psychological nursing, and intraoperative observation of the severity of diseases by circulating nurses; meticulous nursing was given postoperatively. Results: All 50 patients underwent surgery successfully. Intraoperatively, patients had stable physical signs. Five patients had postoperative visual acuity0.3. No complicated infection was seen. Conclusion: For patients diagnosed with proliferative diabetic retinopathy requiring vitrectomy, full preparations should be made and psychological nursing should be delivered preoperatively, the severity of diseases and clinical reactions should be closely observed intraoperatively, and proper processing and nursing measures should be taken postoperatively, which collectively enhance surgical success rate, decrease surgical complications, and attain favorable treatment efficacy.     

糖尿病性白内障与视网膜病变联合治疗的时机和策略

白内障和视网膜病变常并发于糖尿病患者,临床上常面临白内障和视网膜病变联合治疗的决策问题,包括糖尿病性白内障的手术时机,糖尿病视网膜病变的治疗时机及策略,尤其微切口白内障超声乳化手术联合２３Ｇ／２５Ｇ玻璃体切割术以及玻璃体内注射抗血管内皮生长因子和激素等药物为近年的热点问题。随着手术技术、设备、材料和药物的不断进步,使得联合治疗有更多的选择和良好的效果。本文综述了糖尿病性白内障与糖尿病视网膜病变的联合治疗时机及治疗策略的研究进展。     

糖尿病肾病对糖尿病视网膜病变手术治疗时机及疗效的评估价值

目的探讨肾脏疾病对2型糖尿病视网膜病变手术治疗时机及其疗效的评估价值。方法回顾性分析19例行眼底检查的2型糖尿病肾病的临床资料，并根据蛋白尿和肾功能情况，将有视网膜病变患者分为3组。分析糖尿病视网膜病变在各组2型糖尿病肾病中的发生情况和手术治疗效果。结果19例2型糖尿病肾病中15例（78．9％）伴有糖尿病视网膜病变，4例（21．1％）不伴有糖尿病视网膜病变。随着肾功能损伤程度的加重，糖尿病视网膜病变从非增生性进入增生性，重症患者激光或玻璃体切除手术后视功能无改善，病情仍会继续恶化。结论糖尿病视网膜病变的类型与分期与2型糖尿病肾病的严重程度相一致，后者可指导糖尿病视网膜病变手术时机的选择并有助于预后的判断，特别是在眼底无法查清的情况下，糖尿病肾病的临床表现对视网膜玻璃体手术的意义更为重要。     

Vitrectomy in the management of diabetic eye disease.

Vitrectomy techniques including endolaser photocoagulation allow visual rehabilitation in many eyes that are otherwise untreatable. Discerning the indications and timing for diabetic vitrectomy is increasingly important as the treatment of complications of diabetic retinopathy continues to undergo modification and redefinition. The most common indications for diabetic vitrectomy include: 1) severe nonclearing vitreous hemorrhage; 2) traction retinal detachment recently involving the macula; 3) combined traction and rhegmatogenous detachment; 4) progressive fibrovascular proliferation; and 5) rubeosis iridis and vitreous hemorrhage for eyes in which the media opacity has prevented adequate laser photocoagulation. Other less common indications in selected cases include dense premacular hemorrhage, ghost cell glaucoma, macular edema with premacular traction, cataract preventing treatment of severe, proliferative diabetic retinopathy, anterior hyaloidal fibrovascular proliferation, and fibrinoid syndrome with retinal detachment. The rationale and surgical objectives are discussed and results are summarized.     

Vitrectomy in the Management of Diabetic Retinopathy

According to the Early Treatment Diabetic Retinopathy Study, at least 5% of eyes receiving optimal medical treatment will still have progressive retinopathy that requires laser treatment and pars plana vitrectomy. During the past decade, improvements in instrumentation and surgical techniques have allowed more difficult cases of diabetic retinopathy to be candidates for vitrectomy. However, although the thresholds for performing surgery within established indicated situations have been lowered, only a few additional indications have been established. Although vitrectomy improves the prognosis for a favorable visual outcome, preventive measures, such as improved control of glucose levels and timely application of panretinal photocoagulation, produce better results. The authors review the indications, techniques, and results of vitrectomy in the management of diabetic retinopathy.     

The management of diabetic eye disease in the setting of cataract surgery

PURPOSE OF REVIEW: The increased incidence of diabetes mellitus worldwide is accompanied by an increased risk of co-morbid conditions, including the intersection of diabetes, diabetic retinopathy and cataracts. In an effort to improve the surgical outcomes for this population, it is necessary to understand the historical perspectives that have evolved into current treatment recommendations. RECENT FINDINGS: While cataract surgery in patients with no or mild retinopathy may result in minimal complications, a substantial minority of patients with diabetes and advanced retinopathy, including macular edema and a history of previous laser treatment, may require additional considerations when planning cataract surgery. Untreated retinopathy, insufficiently treated retinopathy or treatment failures can be challenging. In these instances, a paradigm shift may be indicated, and the occasion of cataract surgery may provide an opportunity to simultaneously treat retinopathy. By utilizing combined vitrectomy/cataract surgical techniques and/or pharmacologic interventions, improved results for a broader diabetic population may be attainable. SUMMARY: Newer surgical and pharmacologic therapies may now allow for safe and effective surgery in individuals who were previously not candidates for surgery or who had a limited visual prognosis.     

Incidence of rhegmatogenous retinal detachment after vitrectomy in eyes of diabetic patients

PURPOSE: To assess the incidence of rhegmatogenous retinal detachment (RRD) after pars plana vitrectomy (PPV) among diabetic patients with complications of proliferative diabetic retinopathy. METHODS: Ninety-three eyes of diabetic patients-who underwent PPV with or without intraocular gas tamponade for complications of proliferative diabetic retinopathy-were reviewed retrospectively. Indication for vitrectomy was vitreous hemorrhage in 80 patients (86.1%), tractional retinal detachment in 3 (3.2%), and vitreous hemorrhage associated with tractional retinal detachment in 10 (10.7%). RESULTS: Four (4.3%) of 93 eyes developed an RRD after vitrectomy. The primary reason for vitrectomy was recurrent or nonresolving vitreous hemorrhage. The retina was attached with one additional surgical procedure in two of these eyes; the other two had to undergo a third operation before attachment was achieved. CONCLUSION: RRD occurs in a small percentage of patients after PPV with or without gas tamponade for vitreous hemorrhage or tractional retinal detachment caused by proliferative diabetic retinopathy. Thorough postoperative follow-up is important to make early diagnosis and intervention possible.     

Recent outcomes of vitreous surgery for diabetic retinopathy

PURPOSE: To investigate background, surgical method, complications, prognosis, and prognostic factors in patients undergoing vitrectomy for diabetic retinopathy. SUBJECTS AND METHODS: Three hundred and forty eyes of 261 patients undergoing vitrectomy for diabetic retinopathy in five recent years were studied regarding background, surgical method, complications, and visual prognosis. Factors influencing postoperative visual acuity and complications were also examined using univariate and multivariate analyses. RESULTS: Final postoperative visual acuity (FPVA) improved in 226 eyes (66%). FPVA of 0.1 or better and 0.5 or better was achieved in 80% and 45% of all patients, respectively. Postoperative complications occurred in 89 eyes(26%). In the vitreous hemorrhage group, FPVA improved in 86%, and FPVA of 0.5 or better was achieved in 60%. Postoperative complications were most common in the traction detachment group and the percentage was 40%. Factors influencing FPVA were preoperative visual acuity, postoperative complications, indications for surgery, and preoperative severity. Factors influencing postoperative complications were patient background, preoperative visual acuity, preoperative severity, and iatrogenic breaks. CONCLUSIONS: Vitrectomy is a useful method for diabetic retinopathy but postoperative complications must be managed.     

玻璃体切割术后糖尿病黄斑水肿治疗新进展

糖尿病黄斑水肿(DME)是糖尿病视网膜病变(DR)常见的并发症,而DR患者常因玻璃体积血和视网膜脱离等并发症需要行玻璃体切割术,术后DME的治疗方案随着玻璃体内替代物和药物动力学的改变发生变化,目前该病主要的治疗方案有抗血管内皮生长因子药物、糖皮质激素和阈值下微脉冲激光等。本文就玻璃体切割术后DME的治疗进展进行综述。     

晶状体超声乳化联合玻璃体手术治疗合并白内障的增生性糖尿病视网膜病变

目的分析晶状体超声乳化联合玻璃体手术治疗合并白内障的增生性糖尿病视网膜病变(PDR)的疗效。设计回顾性临床病例系列。研究对象123只合并不同程度白内障的PDR患眼。方法对123只合并不同程度白内障的PDR患眼实施晶状体超声乳化联合玻璃体手术治疗,同时I期植入人工晶状体(IOL),观察术后视力改善程度及术中术后并发症。主要指标术后视力改善程度、术后并发症发生率。结果123眼均实施晶状体超声乳化联合玻璃体手术,并同时一期植入IOL于囊袋内。随访时间3￣21月(平均10个月)。99眼(81%)术后均有不同程度的视力改善。其中93眼(76%)术后视力提高2行或以上。术后无明显角膜水肿和角膜内皮失代偿发生。1例I型糖尿病患者术后6个月发生新生血管性青光眼;1眼术后发生视网膜脱离,再次手术后复位;4眼因玻璃体腔出血再次手术。术后视力无明显改善或视力提高不足2行的病例均合并不同程度的糖尿病黄斑病变。结论晶状体超声乳化联合玻璃体手术是提高合并白内障的PDR患者视力的有效手段。糖尿病黄斑病变是影响术后视力提高的主要因素。(眼科,2006,15:198-201)     

Surgery for diabetic retinopathy

Surgery for diabetic retinopathy addresses late secondary complications of a primary microvascular disease. Since surgery is not a causative therapy, the functional outcome of surgery depends on the degree of retinal ischemia and may be disappointing even in technically and anatomically successfully operated eyes. Typical indications for vitrectomy are vitreous hemorrhage, tractional retinal detachment, combined tractional rhegmatogenous retinal detachment and tractive macular edema. More recently diffuse diabetic macular edema has been shown to improve after removal of an attached vitreous in several cases. Neovascular glaucoma requires aggressive surgical intervention to salvage the eye. Cataract surgery is commonly performed in eyes with diabetic retinopathy. It may however deteriorate diabetic eye disease. Vitreous surgery also has a potential for severe complications in diabetic eyes which can be ameliorated but not eliminated by proper surgical strategies and techniques. The decision for an intervention in diabetic eyes always requires a careful weighing of risks and benefits of surgery.     

23-G高速微创玻璃体切割系统在玻璃体视网膜疾病的应用

目的：观察23-G高速玻璃体切割技术治疗玻璃体视网膜疾病的临床效果。

方法：对26例26眼玻璃体视网膜疾病患者,采用23-G高速微创玻璃体切割术进行手术,观察手术效果及手术并发症。术后随访1～6mo。

结果：26眼玻璃体视网膜疾病手术均顺利完成,术中术后无严重并发症发生,手术时间缩短,术后视力得到不同程度改善。

结论：23-G高速玻璃体切割术可广泛适用于玻璃体视网膜疾病,手术效果良好,术后恢复快,是一种安全有效的玻璃体手术方式。     

增生性糖尿病视网膜病变合并白内障的联合手术治疗

目的探讨玻璃体手术联合晶状体超声乳化治疗增生性糖尿病性视网膜病变（PDR）合并白内障的临床疗效。方法分析19例（20只限）增生性糖尿病性视网膜病变合并不同程度白内障患者行白内障超声乳化联合玻璃体手术同时进行人工晶状体囊袋内植入的临床资料，观察术后视力改善程度及术中术后并发症。结果随访2—16个月，所有术眼人工晶状体位置良好，手术后20只限中有16只限（80％）视力有不同程度的提高，其中视力提高二行以上13只限（65％）；视力较术前无改善4只限（20％）。术后视力恢复不佳的原因主要与不同程度的糖尿病黄斑病变、视网膜广泛缺血有关。术后并发症包括高眼压、虹膜后粘连、玻璃体腔再出血、视网膜再脱离、晶状体后囊混浊及新生血管性青光眼等。结论玻璃体手术联合白内障超声乳化人工晶状体植入术治疗增生性糖尿病性视网膜病变合并白内障是安全和有效的，可使大多数患者视力改善，且无明显并发症。     

Postoperative Complications of Pars Plana Vitrectomy for Diabetic Retinal Disease

ABSTRACT

Despite recent advances in the medical management of diabetic retinal disease, there remain established indications for vitreoretinal surgery in the treatment of severe proliferative diabetic retinopathy. These include non-clearing vitreous hemorrhage and tractional retinal detachment. Advances in surgical instrumentation, technique, and experience have led to improved visual outcomes, as well as a corresponding decrease in the incidence of postoperative complications. However, the presence of systemic and ocular factors in diabetic patients increases the risk of adverse events compared to non-diabetic individuals. This review will focus on the most important postoperative complications following pars plana vitrectomy, with specific considerations for the diabetic patient.     

An objective analysis of proliferative diabetic retinopathy before and after pars plana vitrectomy.

Nineteen eyes on which pars plana vitrectomy was performed were studied with fluorescein angiography. The degree of background diabetic retinopathy before and after surgical treatment appeared unchanged. The degree of proliferative retinopathy not only was less after surgical treatment, but continued to show regression with time.     

Subthreshold diode micropulse panretinal photocoagulation for proliferative diabetic retinopathy

PURPOSE: To report the visual acuity and clinical outcomes of a pilot study of subthreshold diode micropulse (SDM) panretinal photocoagulation (PRP) for treatment of diabetic retinopathy.METHODS: A retrospective chart review of all patients undergoing PRP for diabetic retinopathy between April 2000 and February 2003 was performed. Treated conditions ranged from severe non-proliferative to severe proliferative diabetic retinopathy. An SDM PRP protocol designed to avoid detectable laser lesions was employed. Treatment failure end points included the development of vitreous haemorrhage or the performance of vitrectomy.RESULTS: Ninety-nine eyes of 63 patients undergoing SDM PRP were identified. Median follow-up was 1.0 year (range of 0.3-2.7 years). Treatment sessions per eye ranged from 1 to 6 (with a median of two sessions per eye). Overall visual acuity remained unchanged. The probability of treatment failure end points at 12 months post-treatment was 12.5% for vitreous haemorrhage and 14.6% for vitrectomy (from Kaplan-Meier survival analysis). Age, sex, diabetes type, and baseline retinopathy status were not significantly associated with the risk of either failure event. No treatment complications were observed. No eye demonstrated any laser lesion detectable clinically or by fluorescein angiography postoperatively.CONCLUSION: SDM pan retinal photocoagulation minimized retinal damage and treatment complications in the management of high-risk non proliferative and proliferative diabetic retinopathy. Visual loss was prevented with a low rate of vitreous haemorrhage and vitrectomy postoperatively. Further study of the safety, efficacy, and optimal treatment parameters of SDM pan retinal photocoagulation for diabetic retinopathy is warranted.     

Extracapsular cataract extraction and implantation in the capsular sac during vitrectomy in diabetics]

Removal of the lens is often performed during pars plana vitrectomy for complications of proliferative diabetic retinopathy, but correction of aphakia often remains unsatisfactory. Some authors have reported posterior chamber intraocular lens implantation during pars plana vitrectomy in diabetic patients who presented with coexisting cataract and vitreoretinal complications from proliferative diabetic retinopathy. Some patients were operated by pars plana lensectomy and vitrectomy followed by posterior chamber intraocular lens implantation in the ciliary sulcus, others by extracapsular extraction, posterior chamber intraocular lens implantation in the ciliary sulcus, and pars plana vitrectomy. Other authors have described phacoemulsification through the limbus, pars plana vitrectomy and implantation in the capsular bag in one operation in various indications, including complications of proliferative diabetic retinopathy. We inserted a posterior chamber intraocular lens into the capsular bag in 18 eyes of 16 patients with complications of proliferative diabetic retinopathy after extracapsular cataract extraction and pars plana vitrectomy in a single session. A standard extracapsular cataract extraction was performed before pars plana vitrectomy. Sufficient anterior capsule was left in place in order to facilitate implantation in the capsular bag after pars plana vitrectomy. The anterior chamber was filled with sodium hyaluronate in order to maintain anterior chamber depth, corneal clarity, and good mydriasis during the continuation of the procedure. A standard three port pars plana vitrectomy was performed in all cases. After closure of superior sclerotomies, superior corneal incision was partially reopened, an intraocular lens specifically designed for the capsular bag with an optic size of 7 mm was inserted, and the corneal incision was closed with interrupted 10/0 sutures.(ABSTRACT TRUNCATED AT 250 WORDS)     

糖尿病视网膜病变并发症的玻璃体手术治疗和手术并发症控制

糖尿病视网膜病变的并发症已成为玻璃体手术的主要适应证，但手术基本上不是一种病因性治疗;手术后的视功能取决于视网膜缺血和已引起的损害程度。手术本身也可能出现严重并发症。因此,更好的理解糖尿病视网膜病变的临床病理基础,正确掌握手术策略,合理应用手术技术,提高手术技巧,对提高手术效果和减少并发症至关重要。(中华眼底病杂志,2007,23:231-233)     

增殖性糖尿病视网膜病变玻璃体手术并发症分析

目的:探讨糖尿病视网膜病变玻璃体手术并发症及防治。方法:82眼增殖性糖尿病视网膜病变行玻璃体手术治疗,并随访3~24mo,对其术中和术后并发症进行回顾性分析。结果:术后视力较术前不同程度的提高者62眼(72%),但部分患眼出现不同情况的并发症,包括高眼压、玻璃体出血、并发性白内障、医源性视网膜损伤等。结论:糖尿病视网膜病变进行玻璃体手术能挽救大多数眼球并恢复一定的有用视力,但对手术并发症应重视并积极预防治疗,以提高玻璃体手术的效果。     

Types of macular holes encountered during diabetic vitrectomy

PURPOSE: To determine the types of macular holes encountered during vitrectomy for complicated cases of diabetic retinopathy. METHODS: This is a retrospective study of consecutive cases of macular holes diagnosed either before or during pars plana vitrectomy for complications of proliferative diabetic retinopathy over a 6-year period. The morphology of these holes is described. Possible mechanisms of their development, surgical considerations, and results after a follow-up of at least 3 months are discussed. RESULTS: Nineteen consecutive cases of macular holes associated with proliferative diabetic retinopathy were reviewed over a 6-year period. Five cases were lamellar and 14 were full thickness. The 14 cases of full thickness macular holes occurred in patients with the following conditions: tractional rhegmatogenous retinal detachment (5); tractional retinal detachment (3); premacular hemorrhage (3); and cystic macular edema (3). Closure of the full thickness holes was achieved in 8 of 11 patients who were followed up for at least 3 months. All the patients had visual improvement, but no patient had a visual acuity of better than 20/100. CONCLUSION: Macular holes may occur in proliferative diabetic retinopathy in different configurations. Full thickness macular holes can be closed in most cases. Functional improvement can be achieved.