Vitrectomy results for diffuse diabetic macular edema with and without inner limiting membrane removal

PURPOSE: To determine whether vitrectomy for diffuse diabetic macular edema with and without internal limiting membrane (ILM) peeling is equally effective in reducing edema. METHODS: The authors retrospectively analyzed the surgical outcomes in 73 eyes of 52 patients with diffuse diabetic macular edema. Eighteen eyes (Group A) underwent three-port pars plana vitrectomy with posterior hyaloid membrane (PHM) removal, while 55 eyes (Group B) had pars plana vitrectomy with additional ILM peeling after PHM removal. RESULTS: Intraoperatively, the posterior hyaloid was found to be attached to the macula in all eyes. In Group A, macular edema resolved completely in 8 eyes (44.4%) with improvement of visual acuity (VA). In Group B, VA improved in 38 eyes (69.1%) with complete resolution of edema. The results of this study indicated that vitrectomy effectively reduced macular edema but eyes with ILM peeling (Group B) presented better results than those without ILM peeling. Another important factor related to the outcome seems to be the level of glycosylated hemoglobin (HbA1c). CONCLUSIONS: In eyes with diffuse diabetic macular edema vitrectomy seems to be effective, but additional ILM peeling presented better results.     

视网膜内界膜剥离治疗糖尿病黄斑水肿的 疗效观察

目的 评价视网膜内界膜（ILM）剥离对糖尿病黄斑水肿患者手术后视力恢复的影响。探讨吲哚青绿（ICG）在ILM剥离术中的作用。 方法 对30例（31只眼）增生期糖尿病视网膜病变伴黄斑水肿患者行玻璃体切割治疗。患者随机分成两组，A组：单纯玻璃体切割16只眼，手术中行全视网膜光凝及20%SF6眼内填充；B组：玻璃体切割加吲哚青绿(ICG)染色ILM剥离15只眼，在A组术式基础上手术中增加ICG染色后极部ILM，并行ILM剥离。所有患者手术后保持面朝下体位10~14 d。患者定期随访3~12个月。 结果 A组16只眼中，视力提高2行或2行以上10只眼（62.5%），黄斑水肿消退9只眼（56.2%），手术后光相干断层扫描检查黄斑厚度平均393 μm。B组15只眼中视力提高2行或2行以上14只眼（93.3%），黄斑水肿消退14只眼(93.3%)，黄斑厚度平均319 μm。B组手术后视力提高明显优于A组（X²=4.210，P=0.05 Fisher确切检验法）；B组患者手术后黄斑区视网膜厚度明显低于A组（P<0.01独立秩和检验）。手术标本证实为ILM。 结论 玻璃体切割术是治疗糖尿病黄斑水肿的有效方法，ILM剥离能明显提高手术的疗效；ICG能较好地染色ILM，使ILM的剥离更加安全确切。(中华眼底病杂志,2005,21:138-141)     

Optic nerve atrophy after vitrectomy with indocyanine green-assisted internal limiting membrane peeling in diffuse diabetic macular edema

Purpose To report anatomic and visual outcomes of vitrectomy and indocyanine green (ICG)-assisted peeling of the retinal internal limiting membrane (ILM) in the treatment of diffuse diabetic macular edema.Methods In a retrospective interventional case series, 15 eyes of 11 patients with refractory diffuse diabetic macular edema underwent pars plana vitrectomy with removal of the ILM, which was stained by intravitreal injection of ICG (0.1–0.2 ml of 0.5% ICG), performed by a single surgeon. The patients were followed up for 14–28 months (mean 20.5 months). The main outcome measures were assessment of macular edema by optical coherence tomography and determination of visual acuity and visual field.Results Intravitreal ICG visualized the ILM to facilitate complete removal of the structure. Qualitative assessment of optical coherence tomography images at the end of follow-up revealed that retinal thickness in the macula appeared nearly normal with or without reappearance of foveal pit in 11 of the 15 eyes (73.3%), decreased in 3 eyes (20.0%), and did not change in 1 eye (6.6%). Best-corrected visual acuity at the end of follow-up improved by 2 lines or more in 4 eyes (26.7%), virtually unchanged in 6 eyes (40.0%), and deteriorated by 2 lines or more in 5 eyes (26.7%). The mean logMAR visual acuity was 0.680 (approximately 12/60) preoperatively and 0.812 (approximately 9/60) postoperatively, the difference being not statistically significant (paired t-test, P=0.445). Seven (46.7%) of the 15 eyes developed optic nerve atrophy that occurred gradually within 6 months after surgery and caused irreversible peripheral visual field defect predominantly affecting the nasal field.Conclusion Intravitreal application of ICG is beneficial in uneventful ILM peeling to help resolution of diffuse diabetic macular edema, but it may potentially damage the optic nerve fibers and lead to unfavorable visual outcomes.No proprietary interest     

Comparison of anatomical and functional outcomes of different surgical techniques in myopic macular hole without retinal detachment

AIM: To define the anatomic and functional outcomes of pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling, inverted ILM flap and free ILM patch graft technique for the treatment of myopic macular hole (MH) without retinal detachment. METHODS: Sixty-four eyes of 64 patients who underwent PPV for myopic MH were included. Group 1 consists of patients underwent ILM peeling (n=26), and Groups 2 and 3 consists of patient underwent free ILM patch graft (n=20) and inverted ILM flap procedure (n=18) respectively. Outcomes following surgery were MH closure and best corrected visual acuity (BCVA) in logMAR at 6mo. RESULTS: Closure of MH was obtained in 20 eyes (76.9%) of the Group 1, in 16 eyes (80%) of the Group 2 and in 16 eyes (88.9%) of the Group 3. The mean preoperative and postoperative BCVA was 1.60±0.53 logMAR and 1.27±0.58 logMAR, respectively (P<0.05). There was no significant difference in the postoperative BCVA and anatomical closure rates in the three groups. Although the anatomical closure rate did not differ significantly in the groups, closure of MH tended to be better in the inverted ILM flap technique group at 6mo. CONCLUSION: Different surgical techniques may provide favorable visual and anatomical results for myopic MH surgery. ILM flap techniques offer higher closure rates compared to ILM peeling technique. However, in terms of visual outcomes, the study reveals no difference in three surgical techniques.     

Internal limiting membrane peeling in vitreous surgery for diabetic macular edema

PURPOSE: To evaluate the effect of internal limiting membrane (ILM) peeling in vitreous surgery for diabetic macular edema. METHODS: This study was done on 135 eyes of 103 patients who all underwent diabetic macular edema surgery under the same surgeon. The subjects were 74 eyes of 55 males and 61 eyes of 48 females, aged 35-81 years, with an average of 62 years. The postoperative follow-up period ranged from 12 to 39 months, with an average of 20 months. The ILM peeling was performed in 74 eyes. The subjects were divided in two types of macular edema from the presence (type II, 81 eyes) or absence (type I, 54 eyes) of hard exudates in the macular region. We evaluated the effects of the ILM peeling on the absorption rate of macular edema, the period required for absorption of macular edema, and the postoperative visual acuity. RESULTS: The absorption rate of macular edema was more than 90% with or without the ILM peeling. The period required for absorption of macular edema in eyes with ILM peeling was shorter in type II. There was no difference in the postoperative visual acuity with or without ILM peeling. ILM peeling was not an important factor for the postoperative visual acuity. RESULTS: ILM peeling accelerates the absorption of edema in more severe diabetic macular edema, but we could not find any improvement of visual acuity.     

玻璃体切割联合内界膜剥除术治疗顽固性糖尿病黄斑水肿

目的：观察玻璃体切割术(PPV)联合内界膜(ILM)剥除术治疗顽固性糖尿病黄斑水肿的临床疗效。

方法：回顾性分析顽固性糖尿病黄斑水肿并行PPV联合ILM剥除术患者56例56眼,根据有无后极部玻璃体后脱离分为A组(无玻璃体后脱离,35例35眼)和B组(有玻璃体后脱离,21例21眼)。对比分析手术前及手术后1、3、6mo时患眼最佳矫正视力(BCVA)、黄斑中心视网膜厚度(CMT)变化情况。

结果：A组手术后1、3、6mo平均CMT和BCVA与手术前比较均有差异(P<0.05)。B组手术后1、3、6mo平均BCVA与手术前比较均无差异(P>0.05); 手术后1mo平均CMT与手术前比较有差异(P<0.05),术后3、6mo平均CMT与手术前比较均无差异(P>0.05)。术后1、3、6mo,两组CMT、BCVA比较均有差异(P<0.05)。

结论：PPV联合ILM剥除术能有效治疗无玻璃体后脱离的顽固性糖尿病黄斑水肿,提高患者视力; 但当患者玻璃体已经后脱离且没有牵拉时,PPV联合ILM剥除术治疗效果不佳。     

玻璃体切割术联合或不联合内界膜剥除治疗严重PDR伴黄斑皱褶移位

目的:观察性研究25G微创玻璃体切割联合内界膜剥除治疗严重增殖性糖尿病视网膜病变(PDR)伴黄斑皱褶移位的临床疗效。方法:收集2016-01/2017-12在江苏省人民医院眼科病房接受玻璃体切割手术的严重PDR伴黄斑皱褶移位的患者36例36眼的临床资料,其中2016-01/12入院的患者18例18眼纳入对照组,行25G微创玻璃体切割术,2017-01/12入院的患者18例18眼纳入联合组,行25G微创玻璃体切割联合内界膜剥除术。观察术前,术后7d,1、3、6mo最佳矫正视力(BCVA)、黄斑中心区厚度(CMT)、眼压及并发症。结果:术后6mo,两组患者BCVA较术前显著提高(均P<0.05);联合组CMT小于对照组(P<0.001)。术后6mo内,联合组中2眼(11%)高眼压、1眼(6%)黄斑水肿;对照组1眼(6%)高眼压,1眼(6%)黄斑前膜,1眼(6%)玻璃体积血,两组并发症发生率无差异(均P=1.000)。结论:采用25G微创玻璃体切割联合内界膜剥除术治疗严重PDR伴黄斑皱褶移位能安全有效地提高患者视力及降低黄斑中心区厚度。     

Resolution of diabetic macular edema after surgical removal of the posterior hyaloid and the inner limiting membrane

PURPOSE: To evaluate the surgical results of pars plana vitrectomy with peeling of the inner limiting membrane (ILM) in a preliminary series of 12 eyes with diffuse diabetic macular edema. PATIENTS AND METHODS: Pars plana vitrectomy with peeling of the ILM was performed in 12 eyes with diffuse diabetic macular edema. In 10 eyes, the posterior hyaloid was attached and thickened. Six eyes had undergone macular photocoagulation previously, and two other eyes had been vitrectomized previously. Light and electron microscopy of the specimens obtained during vitrectomy was performed. Visual acuity and retinal thickening were monitored. RESULTS: Intraoperatively, the posterior hyaloid was found to be thickened and completely attached to the macula in 10 eyes. Two previously vitrectomized eyes showed a glistening reflex of the vitreoretinal interface but no premacular membrane. The posterior hyaloid and the ILM were removed from the macula. Postoperatively, retinal thickening resolved or decreased in all eyes. Visual acuity improved by at least two lines in 11 eyes. Best-corrected postoperative visual acuity developed within 4 to 12 weeks. No recurrence or deterioration of macular edema or epiretinal membrane formation were observed during the entire period of review (mean, 16 months; range, 8-31 months). Light and electron microscopy showed the presence of the ILM associated with sparse and mostly single-layered fibrous astrocytes. CONCLUSION: Vitrectomy including removal of the ILM leads to expedited resolution of diffuse diabetic macular edema and improvement of visual acuity without subsequent epiretinal membrane formation. Complete release of tractional forces and inhibition of reproliferation of fibrous astrocytes seem to be prudent in the eyes of patients with diabetes and advanced vitreoretinal interface disease of the macula.     

Effects of Internal Limiting Membrane Peeling in Vitrectomy on Diabetic Cystoid Macular Edema Patients

Purpose We evaluated the effects of the peeling of the internal limiting membrane (ILM) during vitrectomy in diabetic cystoid macular edema (CME) patients.Methods Visual outcome and intraoperative and postoperative complications were evaluated retrospectively in 84 CME patients (100 eyes), all of whom had been followed for at least 1 year postoperatively. Before January 2001, we did not perform ILM peeling at our hospitals; 57 patients (66 eyes) treated before 2001 were included in this retrospective study as the non-peeling group. After January 2001, ILM peeling was performed in 27 (34 eyes) CME patients, who were included in this study as the peeling group. In the peeling group, indocyanine green (ICG) staining was performed at the time of ILM peeling.Results Visual acuity improved significantly after vitrectomy regardless of ILM peeling. Visual acuity improved gradually from 6 months to 1 year after the operation, and improved further at the final observation point in both groups. Visual acuity did not differ significantly between the two groups at any time point. There was no difference in the incidence of intraoperative and postoperative complications between the two groups. There were no adverse events associated with ICG-assisted ILM peeling.Conclusions Visual acuity improved with vitrectomy for diabetic cystoid macular edema in both groups. ILM peeling was not found to improve visual acuity postoperatively. Jpn J Ophthalmol 2005;49:297–300 © Japanese Ophthalmological Society 2005     

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.     

Prospective evaluation of intravitreal triamcinolone acetonide injection in macular edema associated with retinal vascular disorders

PURPOSE: To evaluate the effect of intravitreal triamcinolone acetonide on visual acuity and macular thickness using optical coherence tomography (OCT) in macular edema associated with various retinal vascular disorders. METHODS: This prospective nonrandomized clinical interventional study included 81 eyes (76 patients) comprised of Group I, 57 eyes (51 patients) with diabetic macular edema; Group II, 10 eyes (10 patients) with branch retinal vein occlusion; and Group III, 13 eyes (13 patients) with central retinal vein occlusion. All eyes received an intravitreal injection of 4 mg triamcinolone acetonide (with the solvent) in the operation theater under sterile conditions. RESULTS: Mean preinjection central macular thickness was 531.84+/-132 microm in Group I, 458.4+/-149 microm in Group II, and 750.81+/-148 microm in Group III. All groups showed a statistically significant decrease in mean central macular thickness at 1 month (300.7+/-119 microm in Group I, 218.2+/-99 microm in Group II, and 210.5 +/-56 microm in Group III) and 3 months (253.19+/-109 microm in Group I, 187+/-47 microm in Group II, and 182+/-50 microm in Group III) after injection (p < 0.05). Mean follow-up was 22+/-2.4 weeks. Mean visual acuity increased in all three groups (preoperative visual acuity in Group I, 1.2+/-0.4 logMAR units; Group II, 1.24+/-0.5 logMAR units; Group III, 1.1+/-0.4 logMAR units; 1 month postinjection in Group I, 0.88+/-0.3 logMAR units; Group II, 0.67+/-0.3 logMAR units; Group III, 0.86+/-0.4 logMAR units; 3 months postinjection in Group I, 0.84+/-0.4 logMAR units; Group II, 0.59+/-0.3 logMAR units; Group III, 0.82+/-0.5 logMAR units) (p < 0.05). Forty-one eyes completed 6 months and 20 eyes completed 9 months follow-up. Twelve of 20 (41%) eyes in Group I, 2/6 (33%) eyes in Group II, 3/6 (50%) eyes in Group III, and 8/15 (53%) eyes in Group I, 1/3 (33%) eyes in Group II, and 2/2 (100%) eyes in Group III developed recurrence of macular edema with worsening of visual acuity at 6 and 9 months, respectively. Thirty-three (40.7%) eyes developed IOP elevation (at least one reading > 24 mmHg). One eye developed infective endophthalmitis. CONCLUSIONS: Intravitreal injection of triamcinolone acetonide may be considered as an effective treatment for reducing macular thickening due to diffuse diabetic macular edema, venous occlusion associated macular edema, and may result in increase in visual acuity at least in the short term. Further follow-up and analysis is required to demonstrate its long-term efficacy.     

玻璃体手术治疗弥漫性非牵引性糖尿病性黄斑水肿的临床效果

目的 探讨玻璃体切除联合视网膜内界膜剥除术治疗弥漫性非牵引性糖尿病性黄斑水肿的临床疗效.方法 回顾性病例系列研究.回顾性分析21例(21只眼)弥漫性非牵引性糖尿病性黄斑水肿患者的临床资料.所有患者均进行了玻璃体切除联合内界膜剥除术.患者手术前与手术后的黄斑厚度比较,采用定量资料配对t检验;术前与术后不同时间的视力呈非正态分布,采用Wilcoxon秩和检验.结果 患者术后随访12～24个月,平均16个月.术后1个月黄斑厚度由术前的(406±59)μm下降至(291±67)μm(t=9.26),术后3个月黄斑厚度(279±66)μm(t=16.09),术后6个月黄斑厚度(278±71)μm(t=10.15),术后12个月黄斑厚度(280±77)μm(t=9.46),术前与术后不同时间的黄斑厚度比较差异均有统计学意义(P<0.01);表明手术后黄斑水肿情况均有不同程度改善.手术后最终随访,最佳矫正视力改善8例(38.1%),不变11例(52.4%),下降2例(9.5%),术后与术前最佳矫正视力比较差异无统计学意义(Z=1.695,P＞0.01).结论 玻璃体切除联合内界膜剥除术能有效减轻弥漫性非牵引性糖尿病性黄斑水肿患者的黄斑厚度,但多数患者术后视力无明显改善.(中华眼科杂志,2011,47:492-496)

Abstract：

Objective To evaluate the efficacy of vitrectomy combined with internal limiting membrane (ILM) peeling in the treatment of diffuse nontractional diabetic macular edema. Methods It was a retrospective case series study. Clinical records of 21 consecutive patients (21 eyes) with diffuse diabetic macular edema without macular traction were reviewed. All patients underwent pars plana vitrectomy with internal limiting membrane peeling. Main outcome measurements included pre- and postoperative optical coherence tomography (OCT) and visual acuity. Results Postoperative follow-up ranged from 12 to 24 months (mean, 16.3 months). Mean preoperative foveal thickness significantly decreased from (406±59) μm to (291±67) μm at 1 months after surgery (t=9.26,P<0.01), and further decreased to (280±77) μm at 12 months (t=9.46,P<0.01). No differences in visual acuity between preoperative and postoperative were found during follow-up periods. The final best-corrected visual acuity improved in 8 (38.1%) of the 21 eyes, remained unchanged in 11 eyes (52.4%), and decreased in 2 eyes (9.5%). Conclusions Pars plana vitrectomy with internal limiting membrane peeling appears to be beneficial in eyes with diffuse nontractional diabetic macular edema in retinal thickness but visual acuity outcomes showed only minimal improvement as compared to the baseline.     

Anatomic and visual outcomes after indocyanine green-assisted peeling of the retinal internal limiting membrane in idiopathic macular hole surgery

PURPOSE: To report anatomic and visual outcomes after vitrectomy and adjunctive retinal internal limiting membrane (ILM) peeling with and without intravitreal indocyanine green for idiopathic macular hole repair. DESIGN: Retrospective comparative study of consecutive case series. METHODS: Three consecutive groups of idiopathic macular hole cases underwent modifications of surgical technique. Group I (48 eyes of 47 patients) underwent a standard vitrectomy, fluid/gas exchange, and 1 week's face-down positioning, group II (21 eyes of 21 patients) an adjunctive ILM peeling without use of indocyanine green, and group III (28 eyes of 28 patients) an adjunctive peeling of ILM stained with intravitreal application of 0.1 to 0.2 ml of 0.5% indocyanine green dye. RESULTS: Three groups of patients had comparable clinical characteristics as to age, gender, estimated duration of macular hole, preoperative visual acuity, and follow-up time. The rate of macular hole closure after a single surgery, as determined by optical coherence topography was 85.4% in group I, 85.7% in group II, and 100% in group III. Groups I and II showed a statistically significant visual improvement, but group III did not show significant visual acuity improvement as the mean logarithm of the minimal angle of resolution visual acuity was from 0.767 (20/120) preoperatively to 0.691 (20/100) postoperatively (P =.342). Eight cases in group III developed within a few postoperative months of optic disk pallor and irreversible peripheral visual field loss, predominantly affecting the nasal field. CONCLUSIONS: Intravitreal indocyanine green-assisted ILM peeling improves anatomic success in macular hole surgery, but it may potentially lead to unfavorable visual acuity outcome and peripheral visual field loss.     

Visual outcome of patients with macular edema after pars plana vitrectomy and indocyanine green-assisted peeling of the internal limiting membrane

Purpose To evaluate the efficacy of inner limiting membrane (ILM) peeling in persistent macular edema.Methods This retrospective review analyzed a series of 23 eyes from 23 patients with persistent macular edema treated by pars plana vitrectomy (PPV) with indocyanine green (ICG)-assisted peeling of the ILM. Thirteen female and 10 male patients with a mean age of 57.2±15.6 (24–77) years underwent operation between May 2000 and October 2001. The main diagnoses were uveitis (anterior, intermediate, posterior and panuveitis) (n=9), central retinal vein occlusion (CRVO) (n=4), diabetic retinopathy (DR) (n=5), vitreoretinal traction syndrome (n=2), and Irvine–Gass syndrome (n=3). Nine eyes had undergone phacoemulsification (PE) previously and two eyes had been subjected to combined PE and ILM peeling. The eyes were tamponaded with gas (3), silicone oil (5) or air (11). In four cases no endotamponade was used. Improvement in visual acuity of 2 lines or more was regarded as significant.Results Visual acuity improved after 3 months in 9 of the 23 patients. After 6 months and at the follow-up, a significant improvement was found in 6/21 and 7/21 patients. This improvement was predominantly seen in patients with uveitis (5/9), or diabetic maculopathy (3/5); One patient with Irvine–Gass syndrome showed a significant reduction, one with vitreoretinal traction an improvement in visual acuity. The group of patients with CRVO showed no significant change during the follow-up. The choice of endotamponade did not alter the visual acuity outcome.Conclusions Different patient groups respond differently to ILM peeling. Although overall significant visual acuity improvement was observed in only one third of all cases 12 months after ILM peeling for persistent macular edema, patients with uveitis and nonproliferative diabetic maculopathy demonstrated a benefit. The lack of long-term improvement in the majority of cases is in accordance with the hypothesis that ILM peeling may reduce the intraretinal edema, but does not affect the underlying mechanism causing macular edema. So far, only diabetics have shown improvement (still unproven) from ILM peeling, and this study provides no justification for extending the treatment to macular edema of other causes. Large-scale investigations are needed to evaluate the efficacy in certain diagnosis groups.This study was presented in part at the 100th meeting of the German Ophthalmological Society in Berlin, September 2002     

Surgical and anatomical outcomes of pars plana vitrectomy for diffuse nontractional diabetic macular edema

PURPOSE: To prospectively determine the efficacy of vitrectomy combined with intravitreal triamcinolone acetonide (IVTA) injection, internal limiting membrane (ILM) peeling, or both in treating diffuse nontractional diabetic macular edema (ME). METHODS: Patients with diffuse ME of <6 months who had no evidence of macular traction or macular ischemia were included in the study. Patients previously diagnosed with glaucoma underwent vitrectomy with ILM peeling. All other patients were randomly assigned to vitrectomy or vitrectomy with ILM peeling followed by IVTA injection. RESULTS: Forty-two eyes of 38 patients were included in the study. Mean follow-up was 12 months. A statistically significant reduction in macular thickness was found at 1 month to 6 months, disappearing at 12 months. No differences in visual acuity between treatment groups were found during follow-up. Visual acuity improved in 5 (12%) of 42 eyes, remained unchanged in 32 (76%) of 42 eyes, and worsened in 5 (12%) of 42 eyes. Complications included increase in intraocular pressure in 8 (26%) of 31 eyes, mild vitreous hemorrhage in 6 (14%) of 42 eyes, central retinal pigment epithelium changes in 5 (12%) of 42 eyes, and cataract progression in 11 (38%) of 29 phakic eyes. CONCLUSION: In diffuse diabetic ME with no retinal traction, vitrectomy with either ILM peeling or IVTA injection at the end of surgery produces a short-term improvement in retinal thickness but no long-term anatomical or functional improvements.     

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.     

Short-term efficacy of intravitreal bevacizumab for the treatment of macular edema due to diabetic retinopathy and retinal vein occlusion

Purpose: To evaluate the short-term efficacy of intravitreal bevacizumab injection for the management of macular edema due to diabetic retinopathy and retinal vein occlusion. Methods: Patients with macular edema due to diabetic retinopathy, and retinal vein occlusion were treated with intravitreal bevacizumab and evaluated retrospectively. Standardized ophthalmic evaluation, ETDRS visual acuity measurement, and central macular thickness were performed at baseline and 1 month intervals after injection. Results: There were 23 eyes of 21 patients with macular edema due to diabetic retinopathy (14 eyes of 12 patients), and retinal vein occlusion (9 eyes of 9 patients). The mean baseline logMAR visual acuity and central macular thickness were 0.82 ± 0.27 and 604.71 ± 123.62 μm, respectively, in patients with diabetic retinopathy. There was no statistically significant difference between the mean logMAR visual acuity (P = 0.22) and central retinal thickness (P = 0.16) measurements at baseline and 3 months follow-up. The mean baseline logMAR visual acuity and central macular thickness were 0.94 ± 0.48 and 557 ± 113.9 μm, respectively, in patients with retinal vein occlusion. There was a statistically significant difference between the mean logMAR visual acuity and central retinal thickness measurements at baseline and 3 months follow-up (P < 0.01). Almost all of the eyes (88.8%) regained normal foveal configuration. Conclusions: Although our follow-up period was short and the number of patients were limited to provide specific treatment recommendations, intravitreal bevacizumab seems to be more effective for macular edema due to retinal vein occlusion than diabetic macular edema. The favorable short-term results suggest further study is needed.     

Comparative evaluation of vitrectomy and dye-enhanced ILM peel with grid laser in diffuse diabetic macular edema

Background The purpose of this study is to compare the effectiveness of pars plana vitrectomy (PPV) and dye-enhanced peeling of the internal limiting membrane (ILM) with modified grid laser photocoagulation in patients with diffuse diabetic macular edema and to determine if any correlation exists between improvement in visual acuity (functional improvement) and reduction in foveal thickness and macular volume (anatomical improvement). Design This is a randomized, prospective, comparative, interventional study. Method In this study 24 eyes of 24 patients with metabolically stable diabetes and with diffuse diabetic macular edema were evaluated. The patients were randomized to either pars plana vitrectomy with removal of ILM which was done in 12 eyes (ILM group) and modified grid laser photocoagulation carried out in the remaining 12 eyes (laser group). Main outcome measures were (1) the postoperative visual acuity in the form of ETDRS log MAR values, (2) foveal thickness and (3) macular volume as measured by optical coherence tomography. The correlation between improvement in visual acuity and the reduction of foveal thickness and macular volume in both the groups were also evaluated. The results were all subjected to statistical analysis. Results The ETDRS log MAR visual acuity difference between the two groups at the end of 6 months was not clinically significant (P = 0.525). However, foveal thickness and macular volume decreased significantly more in the ILM group compared to the laser group (P = 0.001, P < 0.001, Mann Whitney U test). There was no correlation between the improvement in visual acuity and the reduction of foveal thickness (r = −0.158, P = 0.6) (ILM group), r = −0.155, P = 0.7) (laser group) in both groups. Conclusions PPV with ILM peeling was shown to be beneficial by inducing a statistically significant reduction of macular thickness and macular volume. Visual acuity also demonstrated a trend towards improvement in both the ILM peel group and the grid laser group; however, the comparative VA outcome analysis between the two groups was not significantly different. Besides, there was also no correlation between the reductions of foveal thickness and macular volume with the improvement in visual acuity in either of the groups.     

Idiopathic Macular Epiretinal Membrane Surgery and ILM Peeling: Anatomical and Functional Outcomes

Purpose: Evaluation of the visual and anatomical outcomes following idiopathic macular epiretinal membrane (ERM) removal, with or without internal limiting membrane (ILM) peeling, and review of the literature.

Methods: A retrospective study of 39 eyes operated for idiopathic ERM was conducted. Pars plana vitrectomy was combined with ERM removal and Indocyanine green (ICG) assisted ILM peeling in 24 eyes.

Results: In Group A (without ILM peeling), mean preoperative BCVA was 0.48 logMAR (0.3 in decimal units), whereas mean postoperative BCVA was 0.37 logMAR (0.4 in decimal units). In Group B (with ILM peeling), mean preoperative BCVA was 0.58 logMAR (0.25 in decimal units), whereas mean postoperative BCVA was 0.31 logMAR (0.5 in decimal units). No statistically significant difference was observed between Groups A and B regarding preoperative or postoperative BCVA (p>0.1, Student’s t-test).

OCT measurement of postoperative foveal thickness reveled a significant decrease in thickness in both groups; however, no correlation was observed between postoperative BCVA and postoperative foveal thickness (Pearson’s correlation coefficient?=?0.139; p>0.1).

Conclusions: In spite of final visual acuity improvement following idiopathic ERM removal, recovery of a normal foveal thickness is not achieved in the majority of the cases. ICG assisted ILM peeling does not affect the functional outcome of idiopathic ERM removal.     

Macular hole surgery with or without indocyanine green stained internal limiting membrane peeling

Background: To compare the anatomical and visual outcome in primary idiopathic macular hole surgery with or without indocyanine green (ICG) stained internal limiting membrane (ILM) peeling. Methods: The medical records of the last 40 consecutive eyes receiving primary idiopathic macular hole surgery with gas as internal tamponade performed by a single surgeon were retrospectively reviewed and analysed. All eyes had a follow‐up period of at least 6 months. In the initial 22 consecutive eyes, no ILM peeling was performed (non‐ILM peeling group). The subsequent 18 eyes underwent surgery with ICG‐stained ILM peeling (ILM peeling group). Results: The primary anatomical closure rates were 88.9% and 59.1% in the ILM peeling group and non‐ILM peeling group, respectively. The difference was statistically significant (Fisher's exact test, P = 0.038). Improvement in visual acuity was more marked in the ILM peeling group than in the non‐ILM peeling group, with a mean improvement of 3.6 and 1.3 lines, respectively (two‐tailed t‐test, P = 0.036). There were significantly more cases with improvement of two or more lines of visual acuity after surgery, with 66.7% in the ILM peeling group and 31.8% non‐ILM peeling group (Chi‐square test P = 0.028). However, there was no significant difference in the final postoperative logMAR best‐corrected visual acuity between the two groups (two‐tailed t‐test, P = 0.073). Conclusions: Based on this study, ICG‐stained ILM peeling seems to improve the anatomical and visual outcome in primary idiopathic macular hole surgery. Further studies in this aspect are warranted.