Perfluorocarbon in vitreoretinal surgery and preoperative bevacizumab in diabetic tractional retinal detachment

Abstract

Aim: To describe the en bloc perfluorodissection (EBPD) technique and to demonstrate the applicability of using preoperative intravitreal bevacizumab during small-gauge vitreoretinal surgery (23-gauge transconjunctival sutureless vitrectomy) in eyes with advanced proliferative diabetic retinopathy (PDR) with tractional retinal detachment (TRD).

Methods: This is a prospective, interventional case series. Participants included 114 (eyes) with advanced proliferative diabetic retinopathy and TRD. EBPD was performed in 114 eyes (consecutive patients) during 23-gauge vitrectomy with the utilization of preoperative bevacizumab (1.25 mg/0.05 mL). Patients mean age was 45 years (range, 21-85 years). Surgical time had a mean of 55 min (Range, 25-85 min). Mean follow up of this group of patients was 24 mo (range, 12-32 mo). Main outcome measures included best-corrected visual acuity (BCVA), retinal reattachment, and complications.

Results: Anatomic success occurred in 100% (114/114) of eyes. Significant visual improvement [≥ 2 Early Treatment Diabetic Retinopathy Study (ETDRS) lines] was obtained in 69.2% (79/114), in 26 eyes (22.8%) BCVA remained stable, and in 8 eyes (7%) BCVA decreased (≥ 2 ETDRS lines). Final BCVA was 20/50 or better in 24% of eyes, between 20/60 and 20/400 in 46% of eyes, and worse than 20/400 in 30% of eyes. Complications included cataract in 32 (28%) eyes, iatrogenic retinal breaks in 9 (7.8%) eyes, vitreous hemorrhage requiring another procedure in 7 (6.1%) eyes, and phthisis bulbi in 1 (0.9%) eye.

Conclusion: This study demonstrates the usefulness of using preoperative intravitreal bevacizumab and EBPD during small-gauge vitreoretinal surgery in eyes with TRD in PDR.

Keywords: Avastin; Intravitreal bevacizumab; Intravitreal injections; Minimally invasive vitreoretinal surgery; Perfluorodissection; Proliferative diabetic retinopathy; Tractional retinal detachment; Vitrectomy.

Figure 1

Artist's representation of surgical technique. A: An opening is made with the vitrector in the mid-periphery of the posterior hyaloid; B and C: Perfluorocarbon liquid (PFCL) is injected to separate the posterior hyaloid from the retina. A dual bore cannula (for 23-gauge cases) attached to a 5 cc syringe filled with PFCL is used to separate membranes and posterior hyaloid from the underlying retina; D: Once all the tissues have been separated from the retina, vitrectomy can be continued up to the periphery; E: Endolaser is applied under PFCL; F: An air-fluid and an air-gas (C3F8) exchange exchange are performed to end the case.

Figure 2

En bloc perfluorodissection performed in a case of tractional retinal detachment in proliferative diabetic retinopathy. A: An opening is made with the vitrector in the mid-periphery of the posterior hyaloid; B: Perfluorocarbon liquid (PFCL) is injected to separate the posterior hyaloid from the retina (arrows). A dual bore cannula (for 23-gauge cases) attached to a 5 cc syringe filled with PFCL is used to separate membranes and posterior hyaloid from the underlying retina; C: Once all the tissues have been separated from the retina, vitrectomy can be continued up to the periphery; D: Endolaser is applied under PFCL (shown). An air-fluid and an air-gas (C3F8) exchange are performed to end the case (not shown).