Vitrectomy for cases of diabetic retinopathy

Abstract

Microvascular complications of diabetic retinopathy (DR) may require surgical intervention in the form of vitrectomy. Since its inception, diabetic vitrectomy has evolved with introduction of better instruments, newer techniques, and smaller port sizes. Common indications for diabetic vitrectomy include nonresolving vitreous hemorrhage, tractional retinal detachment, epiretinal membrane, progression of fibrovascular membranes despite laser therapy, recalcitrant diabetic macular edema, and neovascular glaucoma. Preoperative systemic stabilization is essential prior to planning surgery. Surgical techniques commonly used in diabetic vitrectomy are segmentation, delamination, and rarely en-bloc dissection. Modification in surgical techniques such as chandelier-assisted bimanual dissection and pharmacological adjuvants improve surgical outcomes in these patients. Prognosis in these patients could be improved with early intervention. Studies evaluating the outcome of vitrectomy in patients with early proliferative DR are required to understand the appropriate time of intervention in patients. Treatment aimed at arresting the progression of DR and gene therapy are avenues that need further evaluation. The following review will focus on covering the epidemiology of DR, indications of vitrectomy, preoperative considerations, surgical procedures of diabetic vitrectomy, methods of membrane dissection, pharmacological adjuvants to vitrectomy, outcomes of diabetic vitrectomy, and future directions of diabetic vitrectomy.

Figure 1

Segmentation of thick membranes at the posterior pole. Use of 25-gauge vitrectomy cutter to divide the diffuse membrane into smaller and smaller segments such that they can be safely removed

Figure 2

Delamination of fibrovascular membranes at the posterior pole. Pegs of fibrous membrane attached to underlying retina (blue arrows, a). Utilization of horizontal scissors and forceps coupled with chandelier illumination to dissect all the fibrous pegs (focal attachments) from underlying retina. Vitrectomy cutter can also be used in place of horizontal scissors (b). Total release of membrane followed by removal with the use of 25-gauge vitrectomy cutter (c)

Figure 3

Combination of various steps of diabetic vitrectomy. Use of 25-gauge vitreous cutter to make an opening in the posterior hyaloid (a). Bimanual dissection of posterior fibrous membranes using 25-gauge curved scissors and forceps coupled with chandelier illumination (b). Segmentation of fibrous membranes employing a 25-Gauge Vitreous Cutter (c). Postoperative color photograph showing residual membranes in the periphery with an attached posterior pole (d)

Figure 4

Preoperative ultrawide field color photograph of left eye of a patient with partially lasered PDR with tractional diabetic macular edema (a) and corresponding OCT showing distortion and thickening of retinal layers due to tractional component (b). Postoperative ultrawide field color photograph of left eye of the same patient showing tightly adherent residual fibrous membrane at disc with well-lasered and attached retina (c) and corresponding OCT showing residual disruption of retinal layers (d)

Figure 5

Flow chart of management of diabetic TRD with vitrectomy