Outcomes of vitrectomy, membranectomy and internal limiting membrane peeling in patients with refractory diabetic macular edema and non-tractional epiretinal membrane (original) (raw)
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Research Square (Research Square), 2020
Purpose: Evaluating the impact of pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling and intravitreal bevacizumab (IVB) injection to manage refractory diffuse diabetic macular edema (DME). Methods: In the current prospective interventional clinical study, eyes with refractory diffuse DME with no response to a minimum of three times IVB injections, and best corrected visual acuity (BCVA) of equal or more than 20/200 and equal or lower than 20/60 were subjected to PPV with ILM peeling and intravitreal avastin injection. Pre-and post-operative assessments were a comprehensive ophthalmologic evaluation, uorescein angiography, and optical coherence tomography (OCT). BCVA, central macular thickness (CMT) and contrast sensitivity (CS) were major outcomes. Results: Fifteen eyes of 13 cases (mean age: 63±5.19 (range, 54-70) years) were subjected to operation and a follow-up of 3 months. Average BCVA at last test was 0.74 ± 0.19 LogMAR that showed no improvement compared with its value before intervention (0.84 ± 0.14 LogMAR) (P=0.073). Average CMT at last test was 328.26±129 µm that was signi cantly lower compared with its value before operation (450.8±114 µm) (P=0.002) and a signi cant improvement in CS was found (from 16.66 ± 8.99 mm to 18.13 ±1.22mm;p=0.003). CMT and BCVA (correlation coe cient =0.419,p=0.120), BCVA and CS (correlation coe cient =-0.336,p=0.221) , and CS and CMT (correlation coe cient =-0.07,p=0.979) were found with no signi cant correlation. Conclusion: PPV with ILM peeling and IVB regarding refractory diffuse DME reduced macular width along with CS improvement, but does not signi cantly improve visual acuity.
Journal of Ophthalmic Vision Research, 2010
To evaluate the effect of pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling for management of refractory diffuse diabetic macular edema (DME). Methods: In this prospective interventional case series, eyes with refractory diffuse DME unresponsive to macular photocoagulation and/or intravitreal bevacizumab, and best corrected visual acuity (BCVA) ≥20/200 and ≤20/60 underwent triamcinoloneassisted PPV with ILM peeling. Pre-and postoperative evaluations included a complete ophthalmologic examination, fluorescein angiography and optical coherence tomography (OCT). Main outcome measures were BCVA and central macular thickness (CMT). Results: Twelve eyes of 12 patients with mean age of 59.6±3.9 (range, 55-68) years were operated and followed for a mean period of 4.9±1.0 (range, 4-6) months. Mean BCVA at final examination was 0.82 ± 0.18 logMAR which was not significantly better than its preoperative value of 1.00 ± 0.80 logMAR (P=0.959). Visual acuity improved by at least 2 lines in 3 eyes (25%), remained stable in 7 eyes (58%) and decreased by at least 2 lines in 2 eyes (17%). Mean CMT at final examination was 315±95 µm, which was significantly less than its preoperative value of 467±107 µm (P=0.004). Complications included vitreous hemorrhage in 2 and cataract progression in 5 eyes. Conclusion: PPV with ILM peeling for refractory diffuse DME seems to reduce macular thickness, but does not significantly improve visual acuity as observed after an intermediate-term follow up of about 6 months.
Egyptian Journal of Ophthalmology, (Mansoura Ophthalmic Center), 2021
Aim: To evaluate the surgical effects of internal limiting membrane (ILM) peeling with parsplana vitrectomy in diffuse diabetic macular edema with vitreo-macular traction as regard the best corrected visual acuity, central foveal thickness, residual epiretinal membrane and recurrent traction. Methods: The study included twenty eyes of twenty patients with diffuse diabetic macular edema and vitreomacular traction. Seven eyes underwent vitrectomy with ILM peeling (group I) and thirteen eyes underwent vitrectomy without ILM (group II). The inclusion criteria were diffuse diabetic macular edema with optical coherence tomography evidence of vitreo-macular traction with or without epiretinal membrane. Exclusion criteria involved any ocular disease can cause macular edema rather than diabetes mellitus and eyes with macular ischemia. The effect of ILM peeling was evaluated on the surgical outcomes as regard best corrected visual acuity, central foveal thickness, residual epiretinal membrane and recurrent traction at postoperative one, three and six months. Results: Statistically significant improvement of best corrected visual acuity and reduction of central foveal thickness occurred in all eyes postoperatively and over time with statistically insignificant difference between both groups. No eyes in group I and eight eyes in group II showed residual epiretinal membrane with a statistically significant difference between both groups. No eyes in group I and two eyes in group II showed recurrent traction due to residual epiretinal membrane with a statistically insignificant difference between both groups. Conclusion: ILM peeling has an important role in complete removal of epiretinal membrane and prevention of recurrent traction.
ILM peeling in nontractional diabetic macular edema: review and metanalysis
International Ophthalmology, 2017
Purpose To evaluate the effect of internal limiting membrane (ILM) peeling during vitrectomy for nontractional diabetic macular edema. Methods PUBMED, MEDLINE and CENTRAL were reviewed using the following terms (or combination of terms): diabetic macular edema, nontractional diabetic macular edema, internal limiting membrane peeling, vitrectomy, Müller cells. Randomized and nonrandomized studies were included. The eligible studies compared anatomical and functional outcomes of vitrectomy with or without ILM peeling for tractional and nontractional diabetic macular edema. Postoperative best-corrected visual acuity and central macular thickness were considered, respectively, the primary and secondary outcomes. Meta-analysis on mean differences between vitrectomy with and without ILM peeling was performed using inverse variance method in random effects. Results Four studies with 672 patients were eligible for analysis. No significant difference was found between postoperative best-corrected visual acuity or best-corrected visual acuity change of ILM peeling group compared with nonpeeling group. There was no significant difference in postoperative central macular thickness and central macular thickness reduction between the two groups. Conclusions The visual acuity outcomes in patients affected by nontractional diabetic macular edema using pars plana vitrectomy with ILM peeling versus no ILM peeling were not significantly different. A larger prospective and randomized study would be necessary.
Macular Hypotrophy After Internal Limiting Membrane Removal for Diabetic Macular Edema
Retina-the Journal of Retinal and Vitreous Diseases, 2014
Purpose: To compare the anatomic and functional effects of three different approaches to nontractional diabetic macular edema. Methods: Retrospective comparative study. Sixty eyes of 60 patients diagnosed with cystoid diabetic macular edema and treated with 1.25 mg/mL intravitreal bevacizumab (Group A), laser photocoagulation (Group B), or vitrectomy with inner limiting membrane peeling (Group C) were included in the study. Changes in number of Early Treatment Diabetic Retinopathy Study letters, central macular thickness, largest diameter of the intraretinal cysts (IC), and choroidal thickness were investigated. Analyses were performed during follow-up visits at Months 1, 3, 6, 9, and 12. Results: Visual acuity only significantly improved in Group A at the last follow-up (P = 0.004). Central macular thickness significantly decreased in every group throughout the follow-up period. Differences in central macular thickness between Groups A and B (P , 0.01), A and C (P , 0.01), and B and C (P , 0.01) were significant. Intraretinal cysts also significantly decreased in each group throughout the follow-up period. Differences in IC size between Groups A and B (P = 0.8), A and C (P = 0.1), and B and C (P = 0.1) were not significant. Choroidal thickness did not undergo any significant change in any group throughout the follow-up period. A significant correlation was also found in Group A between best-corrected visual acuity at month 12 and baseline central macular thickness (R = 0.3; P = 0.006), and in Group B between postoperative best-corrected visual acuity at month 12 and baseline IC size (R = 0.8; P , 0.01, negatively correlated at 92.4%). Conclusion: According to our retrospective data, diabetic macular edema with intraretinal cysts larger than 390 mm should not be treated with vitrectomy with ILM peeling, because this may induce subfoveal atrophy, defined as the "Floor Effect," and subsequent visual deterioration.
Graefe's Archive for Clinical and Experimental Ophthalmology, 2009
Background Histopathologic and morphometric analysis of the internal limiting membrane (ILM) in diabetic eyes was performed. The thickness of the ILM was correlated with the level of glykosylated hemoglobin (HbA 1C) and other clinical factors. Methods The prospective study involved 56 eyes of 52 diabetic patients with a mean age of 63 ± 7.6 years. Vitrectomy with trypan blue-assisted ILM peeling was performed in the standard way. The mean follow-up period was 8.7 months (range 3-19 months). The ILM was fixed immediately after peeling in 2.5% glutaraldehyde and submitted for electron microscopic evaluation. The ILM was photographed at standard magnification (×5,000) with the scale of 1 µm in the shot. Results Morphometric analysis demonstrated a significant thickening of the ILM in all eyes, with a mean thickness of the ILM of 3.61±1.22 µm. It was found that a higher thickness of the ILM is related to elevated HbA 1C in both types of diabetes mellitus (DM) (p=0.040). We also found significant dependence of ILM thickness in relation to duration of DM by comparison of men and women (p=0.026), and a significant correlation between ILM thickness and the age of diabetic patients related to their gender (p=0.029). Conclusions We confirmed increased thickness of the surgically peeled ILM and statistically significant correlations to elevated HbA 1C in both types of DM, and to further clinical characteristics of case series. Morphometric and histopathologic analyses of the ILM contribute to more objective evaluation of the ultrastructure of the vitreomacular interface.
Purpose: To examine the effect of internal limiting membrane (ILM) removal on epiretinal membrane (ERM) surgery by comparing best-corrected visual acuity (BCVA), optical coherence tomography central macular thickness (CMT) changes, ERM recurrence, and need for repeat surgery. Methods: Retrospective study of 251 consecutive patients (251 eyes) who underwent pars plana vitrectomy for idiopathic ERM by a single surgeon with over 1 year of follow-up data. Data were collected preoperatively and postoperatively at 3 months, 1 year, 2 years, and at the last visit. The ILM was not specifically removed in the earlier group of patients and was removed after staining of the ILM in the later group. Results: One hundred and forty eyes (55.8%) did not have an ILM peel (non-ILM group), and 111 eyes (44.2%) did have an ILM peel (ILM group). There were no significant differences between groups in age, gender, preoperative BCVA, preoperative intraocular pressure, preoperative CMT on optical coherence tomography, and cataract status. Total follow-up time for the ILM group was 32.1 months and 45.4 months for the non-ILM group (P = 0.002). Both groups had improvement in BCVA. The ILM group improved by 12 Early Treatment Diabetic Retinopathy Study letters and the non-ILM group improved by 10.5 Early Treatment Diabetic Retinopathy Study letters. There was no significant difference in the final BCVA (P = 0.18) or total change of BCVA (P = 0.48). Cataract status preoperatively did not affect the total change of BCVA, but being phakic at the most recent visit was associated with a slight loss of visual acuity. Both groups had improvement in optical coherence tomography appearance, for the CMT in the ILM group decreased by 83 mm and the CMT in the non-ILM group decreased by 110 mm. There was no significant difference in the final CMT (P = 0.07); however, the non-ILM group tended to have a lower final CMT. Some degree of ERM recurrence was detected by slit-lamp biomicroscopy in 2 eyes (1.8%) of the ILM group and in 32 eyes (22.9%) of the non-ILM group (P # 0.0001). None of the eyes with ILM removal required repeat vitrectomy, whereas 17 eyes (12.1%) of the non-ILM group did require vitrectomy, showing that ILM removal had a significant effect on the need for repeat vitrectomy (P , 0.0001) between non-ILM versus ILM peel groups. Conclusion: The rate of recurrent ERM and need for repeat ERM surgery is lower in eyes where the ILM is removed with the ERM, whereas BCVA and CMT were similar with or without ILM removal. Complete ILM removal around the macula should be considered for the treatment of eyes with idiopathic ERMs to reduce the incidence of ERM recurrences. RETINA 0:1–8, 2016
Graefes Archive for Clinical and Experimental Ophthalmology, 2005
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 μm compared to a postoperative average of 311 μm (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.