Refining vitrectomy for proliferative diabetic retinopathy

Abstract

Pars plana vitrectomy (PPV) is the main treatment modality for patients with severe diabetic retinopathy. With the development of systems for microincision, wide-angle viewing, digitally assisted visualization, and intraoperative optical coherence tomography, contemporary PPV for diabetic retinopathy has been performed on a wider range of indications than previously considered. In this article, we reviewed, in conjunction with our collective experiences with Asian patients, the applications of new technologies for PPV in eyes with diabetic retinopathy and highlighted several important procedures and entities not generally reiterated in the literature, in order for vitreoretinal surgeons to optimize their approaches when facing the challenges imposed by the complications in diabetic eyes.

Keywords: Diabetic retinopathy; Fibrovascular proliferation; Pars plana vitrectomy; Retinal detachment; Vitreous hemorrhage.

Fig. 1

A schematic presentation of assorted vitrectors. Conventionally, different instruments are required to serve different functions. a illustrates conventional scissors for segmentation and delamination, b indicates a cutter to remove the vitreous, and c shows the bimanual incorporation of forceps to lift the membrane and scissors to cut. Nowadays, a small gauge vitrector as shown in d collectively serves the aforementioned purposes. The surgeon is able to cut and aspirate the vitreous, dissect the overlying membrane, and engage tissues by suction all in the same device

Fig. 2

Procedural outline of vitrectomy. a After core vitrectomy, the extent of retinal detachment is verified. b Careful dissection at a suitable plane is performed to release the anterior-posterior traction force. c Tangential traction is further released by removing fibrous tissues. d After careful examination of unattended retinal breaks with diathermy, fluid-gas exchange is performed to facilitate retina flattening. e Once the vitreous cavity is filled with gas, supplementary photocoagulation is applied to enhance break repair, followed by checking sclerotomy leaks at the end

Fig. 3

An optical coherence tomography image of ERM and fibrovascular proliferative tissue over the detached retina. The apparent but false surgical plane is indicated by the red arrow, whereas the true surgical plane is indicated by the green arrows

Fig. 4

Fundus images of eyes before (a and b) and after (c) peripheral retinectomy

Fig. 5

Fundus and optical coherence tomography images of a a subretinal band across the macula, and b the retina reattached under silicone oil after subretinal band removal

Fig. 6

Representative images of thick and localized preretinal hemorrhage under silicone oil which evolved to fibrosis. The thin layered blood is shown in bright red and the thick blood in dark red