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PARS PLANA VITRECTOMY WITH INTERNAL LIMITING MEMBRANE PEELING FOR DIABETIC MACULAR EDEMA

KRISTEN L. HARTLEY, MD, WILLIAM E. SMIDDY, MD, HARRY W. FLYNN JR., MD, TIMOTHY G. MURRAY, MD
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 2 line increase in VA from baseline, 54% of eyes had no improvement in VA, and 21% of eyes had 2 line decrease in VA. Of 9 eyes with pre- and postoperative OCT, there was an overall reduction in central macular thickness of 141 m at postoperative month 3 and 120 m at last follow-up. Postoperative complications included progression of cataract in 6 (60%) of 10 phakic eyes, postoperative intraocular pressure 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. RETINA 28:410 – 419, 2008

D

iabetic macular edema (DME) is the leading cause of visual loss in patients with diabetes mellitus.1 The Early Treatment Diabetic Retinopathy

From the Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami, Miller School of Medicine, Florida. Supported in part by Research to Prevent Blindness. Reprint requests: William E. Smiddy, MD, Bascom Palmer Eye Institute, PO Box 016880, Miami, FL 33101; e-mail: wsmiddy@ med.miami.edu

Study (ETDRS) showed that focal laser photocoagulation is beneficial in the treatment of clinically significant macular edema, reducing the rate of moderate visual loss by 50%.2 Only a small percentage of eyes had improved by 3 lines by the end of the study, probably in large part because a majority of eyes had 20/25 visual acuity at ETDRS entry; among eyes with 20/40 at baseline, 16% gained 3 lines after focal laser. However, up to 25% of eyes sustained
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increased intraocular pressure. 16 had Type II diabetes. 6 months. Separation of the posterior hyaloid was initiated by suction with the vitrectomy instrument and/or a soft-tipped cannula in the cases with attached hyaloid. with mixed success. vitreous There were 24 eyes of 23 patients identified for inclusion in this study (Table 1) including 13 males and 10 females with a mean age of 67 years (range.24. The Human Subjects Committee of the University of Miami Miller School of Medicine approved the study protocol. Eyes with decreased visual acuity caused by other. 28 –79 years). consecutive. removal of this layer using vitrectomy (PPV) techniques has been associated with improved vision in uncontrolled studies. mostly pilot. case series of eyes with diffuse diabetic macular edema that underwent vitrectomy with peeling of the ILM from January 1. best-corrected Snellen visual acuity. There were 10 (42%) eyes that received both laser and intravitreal injections before surgery. Nineteen had systemic hypertension. were elevated with a combination of a barbed microvitreoretinal blade. 7 patients used insulin only. Nineteen eyes had visible preretinal traction preoperatively including direct foveal traction in 8 eyes. duration of visual symptoms. or recurrence of DME. The ILM and ERM. when available. persistently attached posterior hyaloid. 2005. prominent fibrovascular proliferation. if present. and 8 used oral agents alone. retinal detachment. history of focal and panretinal photocoagulation. There were 8 (33%) of the 24 eyes that received neither laser nor intravitreal injections due to what seemed to be a very prominent tractional component. type and duration of diabetes. The mean duration of diabetic macular edema before PPV was 22 months (range. 2–38 months). Preoperative data included age. Results Demographics Methods The study design was a retrospective. Seven with previously recognized proliferative diabetic retinopathy had received prior panretinal photocoagulation. and presence. to December 1. macular ischemia. Intraoperative data included use of intravitreal triamcinolone. postoperative complications. potentially confounding ocular pathology such as vitreous hemorrhage. Intravitreal corticosteroids and antiVEGF agents have been tried in such cases. Eight eyes were from patients who had Type I diabetes mellitus. There were 11 right eyes and 13 left eyes. . Fifteen (63%) eyes had undergone focal or grid macular laser photocoagulation for clinically significant macular edema. 8 used both insulin and oral antihyperglycemic agents.2 Diffuse DME is generally recognized to be less responsive to laser treatment and may account for much of the visual decline and lack of larger visual improvement. 3 months. presence of systemic hypertension. optical coherence tomography (OCT) and fluorescein angiography (FA). diffuse DME. Large cysts were present preoperatively in 12 eyes.21–23 These results parallel the observation that edema improved after spontaneous posterior vitreous detachment (PVD) in some eyes. use of indocyanine green (ICG). Eleven (46%) had received at least one previous intravitreal triamcinolone injection. 1–93 months). or Michels pick. or retinal detachment. The ILM was more broadly peeled using fine intraocular forceps. previous ocular surgery. resolution.PPV WITH ILM PEELING FOR DIABETIC MACULAR EDEMA ● HARTLEY ET AL 411 moderate visual loss over 3 years despite laser treatment. and previous vitreoretinal surgery were excluded. taut. Tano brush. studies have reported promising results for vitrectomy with or without ILM peeling for diffuse DME. gender. stereoscopic biomicroscopy of the vitreous and the vitreomacular interface. The last medical or laser treatment for diabetic macular edema had occurred a mean of 9 months before surgery (range. and complications. but a 25-gauge system was used in one eye. and final follow-up.25 The development of techniques to remove the internal limiting membrane (ILM) has led to its use in a range of vitreoretinal disorders. The attachment at the optic nerve head was usually released by aspirating with the vitreous cutter suction.31– 64 The objective of this study was to investigate the results of vitrectomy with ILM peeling in eyes with refractory. hemorrhage. Visual acuity was converted to logMAR equivalents for the purposes of statistical analysis. 6 weeks.26 –30 Many. The best-corrected Snellen visual acuity (BCVA) was evaluated at baseline. A standard three-port pars plana vitrectomy was performed. The macular edema was evaluated at each of these time intervals clinically with stereoscopic funduscopy and occasionally with OCT or fluorescein angiography. and. usually a 20-gauge system was used. and to review the volumes of reports that have recently appeared on this topic.3–20 A small subset of eyes with macular edema have a thickened. Postoperative data included best-corrected visual acuity at week 6. but anatomic results have generally been more satisfying than visual results. months 3 and 6. 2000. such as cataract formation. and last follow-up.

Neither triamcinolone nor laser seemed to affect the anatomic or visual outcome.3 0.48 Follow-up Days 581 684 253 288 183 449 358 174 92 271 138 85 43 309 65 127 161 54 71 345 61 258 363 *logMAR.18 1 0.48 1 1. Glaucoma filtering surgery had been performed in 1 eye. 0.54 0. Twenty-five percent (6/24) of eyes gained at least 2 lines of Snellen acuity.4 0.4 0.7 0. THE JOURNAL OF RETINAL AND VITREOUS DISEASES ● 2008 ● VOLUME 28 ● NUMBER 3 Table 1.3 0. A fluid-air exchange was performed in 3 eyes.4 1. Uncomplicated cataract extraction with implantation of an intraocular lens had been performed previously in 10 eyes. The duration of the interval between cataract extraction and vitrectomy was at least 1 year since surgery and usually several years.00).54 0.3 1.30 –1. Intravitreal triamcinolone was injected at the end of surgery in 7 eyes. A gas-fluid exchange with C3F8 was used in one eye with more adherent vitreomacular traction to aid in preventing possible macular hole formation. the remaining 14 eyes were phakic at the time of surgery. and 54% (13/24) showed stable vision.48 0. and one to aid in closure of the sclerotomies after a sutureless 25-gauge PPV. Mean logMAR visual acuity at final follow-up was 0. the eyes in this series were selected because the macular edema was judged to be due to diabetes. None of the patients had undergone previous vitreoretinal surgery. 43 days–2 years).3 0. but the subgroup was small.3 0. In 6 of the .10 –2. Mean preoperative logMAR vision was 0.4 0. 21% (5/24) had a decline in vision of at least 2 lines.48 2 1. PCIOL posterior chamber intraocular lens. was unchanged in 4 cases. this group did not seem to behave differently from those not receiving intravitreal triamcinolone.3 0. There was no statistically significant difference between preoperative and postoperative visual acuity at any of the follow-up visits (Figures 1 and 2). Phacoemulsification with implantation of an intraocular lens preceded the vitrectomy during the same procedure in 4 eyes.4 1 0.48 1 1.18 1.3 1.82 1 0. The visual acuity improved 2 lines in 2 cases (but both had a combined cataract extraction). While a mixed mechanism could be possible in some cases.3 1 0. 0. Preoperative Characteristics of Patient Undergoing Vitrectomy for Diffuse Diabetic Macular Edema Patient 1 2 3 4 5 6 7 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Age 28 79 70 73 67 76 66 66 73 67 65 67 78 71 61 64 76 58 66 64 66 60 71 79 Sex F M F F M F F F M F M M M M M F F F M M M F M M Eye R R L L R R L R L L R L L L L R L R R L R L R L Lens Status Phakic PCIOL Phakic Phakic Phakic PCIOL Phakic Phakic PCIOL Phakic PCIOL PCIOL PCIOL PCIOL Phakic Phakic PCIOL Phakic Phakic PCIOL PCIOL Phakic Phakic Phakic Preoperative Acuity* 0.48 1. the mean preoperative foveal thickness of 406 m (range.6 0.4 0.48 Postoperative Acuity* 0.3 0.6 1.4 1.3 0. Anatomic Results In the 9 eyes that had both preoperative and postoperative OCT measurements (center point thickness).3 1.3 0.1 0. 155– 474 m) at final follow-up (Table 2). Thus.6 0.54 1 0. and decreased 2 lines in one case.82). one to provide tamponade of a limited intraoperative suprachoroidal hemorrhage. Endolaser was applied in 6 eyes with previously inactive PDR because of bleeding during separation of the posterior hyaloid. The mean final follow-up interval was 8 months (range. Intraoperative Results Indocyanine green dye was used to stain the ILM in 11 eyes. one due to an inferior retinal tear found intraoperatively.782 (range.412 RETINA.3 0.5 1. 214 –717 m) improved to 286 m (range.3 0.771 (range.

Postoperatively. The patient underwent pars plana vitrectomy with internal limiting membrane peel. cardiac and renal failure. A second eye developed a small inferior retinal break during surgery which was treated with endolaser and a fluid-air exchange without later complication. Fluorescein angiography (FA) demonstrated diffuse leakage of the perifoveal vasculature without a significant focal source.2 Damage to the endothelium and pericytes due to glycosylated products and other mediators such as insulinlike growth factor (IGF1). The distribution of visual acuity change in the subgroups studied with OCT was similar to the others.71 Perhaps intravitreal corticosteroids have some effect to decrease macular edema mediated by these cytokines. Fundus photograph shows evidence of previous focal laser. systemic hypertension. intraoperatively the hyaloid was confirmed to be attached and a posterior vitreous detachment was induced during surgery.3–20 How- . insulin use. The patient’s visual acuity was 20/70 (logMAR 0. A. Macular edema resolved. D. a meaningful analysis was limited by these small numbers. which may be more common in association with these factors. proteinuria.54) 19 months postoperatively. Optical coherence tomography (OCT) demonstrated foveal thickening to 302 m with intraretinal cystic spaces. but then recurred in 4 eyes during the follow-up interval. Funduscopic examination disclosed macular edema with cystic changes associated with early nonproliferative diabetic retinal changes. obesity. C. and vitreous hemorrhage in 2 (8%) eyes. the central thickness was reduced postoperatively by a mean of 199 m.PPV WITH ILM PEELING FOR DIABETIC MACULAR EDEMA ● HARTLEY ET AL 413 Fig. a posterior vitreous detachment was not present. Discussion The pathogenesis of DME is likely multifactorial and probably influenced by duration of diabetes. 9 eyes (67%). Postoperative complications included cataract formation in 6 (60%) of 10 phakic eyes. responds poorly to ETDR-style laser photocoagulation. B. A 79-year-old man with Type 2 diabetes had visual loss to 20/80 (logMAR 0. A limited suprachoroidal hemorrhage occurred in 1 eye intraoperatively. and previous panretinal photocoagulation. which resolved with observation alone. there was an associated epiretinal membrane (ERM).69. and an ERM without vitreomacular traction. high glycosylated hemoglobin. One patient required a glaucoma drainage implant due to persistently elevated intraocular pressure despite maximum medical therapy. vascular endothelial growth factor (VEGF). and histamine may be a common pathogenic pathway to capillary leakage. 1.6) in his right eye despite four prior laser treatments and two intravitreal triamcinolone injections.68 It has been observed that vasodilatation precedes DME.70 and conversely that vasoconstriction follows laser treatment. however.65– 67 A diffuse DME pattern. the cystic changes resolved and OCT measurements demonstrated decreased thickness with a central foveal thickness of 155 m. intraocular pressure 30 mmHg in 6 (25%) of 24 eyes.

A. might be expected to exacerbate vascular leakage. The patient underwent pars plana vitrectomy with internal limiting membrane peel. 2. intravitreal corticosteroids have generally had a more impressive anatomic than visual effect. Macular Thickness as Measured by Optical Coherence Tomography (OCT) Patient 2 3 5 6 8 10 15 22 23 Baseline OCT ( m) 302 481 297 663 717 308 214 318 357 Postoperative OCT ( m) 155 279 241 212 474 403 211 342 262 Change OCT ( m) –147 –202 –56 –451 –243 95 –3 24 –95 Fig. THE JOURNAL OF RETINAL AND VITREOUS DISEASES ● 2008 ● VOLUME 28 ● NUMBER 3 Table 2. taut. Gandorfer et al showed that vitrectomy with ILM peeling led to expedited resolution of diffuse diabetic macular edema with 92% experiencing improvement of visual acuity.32 Patel et al. an ERM.48) 6 months postoperatively.38 In the group undergoing vitrectomy without ILM peeling the edema was usually diminished. the anatomic results have also been more encouraging than visual results (Table 4).52. the cystic changes decreased and OCT measurements demonstrated a reduced central foveal thickness of 474 m. and VMT. Postoperatively. however. and may be deactivated by vitreous surgery. This phenomenon may play a role in cases after vitrectomy. there was minimal improvement in visual acuity after PPV with ILM peeling. perhaps by ILM peeling.414 RETINA. Optical coherence tomography demonstrated foveal thickening to 717 m with intraretinal cystic spaces. but represents a very small subset of those with DME. there was evidence of an epiretinal membrane (ERM) with vitreomacular traction (VMT). It is less intuitive how a vitrectomy with or without ILM peeling might reduce leakage without evident traction. ever.74 In the group undergoing ILM peeling. showed that despite reduction in central macular thickness as measured by optical coherence tomography (OCT).31– 64 The rationale for surgical treatment has been that tractional effects might be more subtle than can be detected even by OCT. a vasodilator. partially attached posterior hyaloid has been reported (in uncontrolled studies) to respond favorably to PPV. a posterior vitreous detachment was not present. However. It has also been hypothesized that removing the ILM allows clearance of edema though removal of a permeability barrier73. intraoperatively the hyaloid was confirmed to be attached and a posterior vitreous detachment was induced during surgery. B. Funduscopic examination revealed an edematous macula with cystic changes associated with severe nonproliferative diabetic retinal changes. The visual acuity was 20/60 (logMAR 0. Vascular endothelial growth factor (VEGF) likely mediates this sequence. There are a few notable findings and contrasts from the many studies of vitrectomy for macular edema. The subset of patients with DME associated with a thickened. yet many have reported that DME decreased after such intervention (Tables 3–5).60 The largest . substantial visual improvement has been reported only in smaller studies. Holekamp et al has demonstrated that intravitreal oxygen tension in diabetic patients is increased after vitrectomy75.57. but other mechanisms may be operating.72 It is consistent with intuition that traction-mediated effects could stimulate leakage that might be reversible upon release. A 73-year-old man with Type 2 diabetes had visual loss to 20/80 (logMAR 0. perhaps vitreous removal itself may have a similar effect. oxygen. however. frequently quite markedly (Table 3).6) in his left eye.21–23 even when broader (OCT) criteria are applied.

N/A not available. N/A not available.5% 11. as in the current series.5% 52% 43% 5% 43% 50% 7% 92% 8% 0 69% 14% 17% 67% 33% 0 60% 20% 20% 91% 0 9% Mean 2 of 0. there were no statistically significant visual differences. the complication rates of this surgical approach are acceptably low. Thomas et al76 reported no benefit of PPV with ILM peeling over further macular laser in patients with chronic DME without macular traction.3% Partial 0 N/A m ¡ post-op m ¡ post-op m ¡ post-op m ¡ post-op 0 m ¡ post-op 20% 20% 12.04 logMAR units 52% 32% 16% 40% 60% 0 50% 50% 0 Mean 2 of 0.1% 66. ETDRS Early ILM internal limiting membrane.4% 31. OCT Treatment Diabetic Retinopathy. and are similar to series involving vitrectomy and membrane peeling. As a general rule. have been noncomparative. Also.1% 41. VA series of 59 eyes showed little change in visual acuity.3% 0 57% 43% 0 53. Vitrectomy Without Peeling Internal Limiting Membrane. optical coherence tomography.7% 100% 0 0 No change in VA after surgery 85% 0 15% 45% 49% 6% Median 1 of 2 ETDRS lines Median 1 from 20/100 ¡ 20/50 43% 50% 7% 71% 19% 10% 17% 83% 100% 0 0 80% 10% 10% 50% 50% 0 49.7% 33. most studies have involved small numbers of patients.8% 9.7% m ¡ post-op m ¡ post-op 0 Persisted 0 N/A 0 225 m 280 m 201 m 264 m 0 327 m 20% 0 40% 5. They suggested that abnormally thickened ILM might play a role as a diffusion barrier to the retina for Table 4. in the current and previous series. Vitrectomy With Internal Limiting Membrane Peeling 2 Edema (Exam/OCT) Study Rosenblatt Avci46 Dillinger31 Gandorfer32 Kolacny36 Kimura35 Radetzky39 Recchia40 Shah41 Stolba43 Yanyali45 Yanyali 44 Thomas75 Jahn33 ILM 47 Visual Acuity Improved Unchanged Worse No. ILM Taut Year Eyes Peel Hyaloid 2005 2004 2004 2000 2005 2005 2004 2005 2006 2005 2006 2005 2005 2004 26 21 60 12 29 21 5 11 33 25 10 12 19 30 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No 5-Yes N/A N/A Yes 6-Yes N/A N/A 6-Yes N/A No No No No Complete Pre-op 575 33% 12% 50% 69% Pre-op 553 N/A Pre-op 421 Pre-op 465 Pre-op 544 Pre-op 391 Pre-op 439 Pre-op 403 74% Partial Persisted m ¡ post-op 311 m 48% 19% 80% 8% 50% 0 31% m ¡ post-op 221 m N/A N/A m ¡ post-op 188 m m ¡ post-op 326 m m ¡ post-op 484 m m ¡ post-op 226 m m ¡ post-op 220 m m ¡ post-op 330 m 26% 50% 38. The mechanism for resolution of DME after ILM peeling hypothesized by Gandorfer et al is that ILM removal may not only result in release of tractional forces.58 Several studies have compared ILM peeling to vitrectomy alone.5% 248 m 269 m 1. . and have not been controlled.5% visual acuity.8% Pre-op 501 Pre-op 622 98. although macular edema (when objectively comparable) decreased. but may also prohibit the reproliferation of fibrous astrocytes on the retinal surface.77– 80 They reported that ILM taken from diabetic macular edema cases were almost twice as thick as the ILM taken from macular hole cases. With or Without a Taut Hyaloid 2 Edema (Exam/OCT) Study Ikeda Ferrari53 Yang60 Yamamoto54 Patel38 Yamamoto64 Yamamoto56 LaHeij57 Parolini58 Ikeda59 Lewis22 Harbour21 Pendergast23 Higuchi63 Otani61 Tachi62 52 Visual Acuity Improved Unchanged Worse No.32 The ILM is known to play an important role as a scaffold for proliferating astrocytes. although none has been randomized (Table 5). Again. OCT optical coherence tomography.05 logMAR units 56% N/A N/A internal limiting membrane.PPV WITH ILM PEELING FOR DIABETIC MACULAR EDEMA ● HARTLEY ET AL 415 Table 3.0% 15. ILM Taut Year Eyes Peel Hyaloid 1999 1999 2000 2003 2006 2004 2001 2001 2004 2000 1992 1996 2000 2006 2002 1996 3 18 13 65 12 19 30 21 59 5 10 10 55 3 7 58 No No No No No No No No No No No No No No No No No N/A N/A N/A No N/A N/A No N/A No Yes 7-Yes Yes Yes No N/A Complete 100% N/A 100% Pre-op 464 Pre-op 334 Pre-op 510 Pre-op 478 100% Pre-op 463 60% 80% 60% 81.

controlled trial will clarify the role of vitrectomy or importance of ILM peeling in DME. N/A triamcinolone injected. A similar inconsistency is seen in many laser-treated eyes.0 69.416 RETINA. Early Treatment Diabetic Retinopathy Study research group.82 Perhaps averting a poor natural history in such cases may justify surgery. may improve the local oxygen supply of the macula from the vitreous. caution is advised regarding visual improvement in patients undergoing vitrectomy for diabetic macular edema in the absence of preretinal traction. Eyes 2005 2006 Yes No Yes No Yes No Yes No Yes No Yes No IVTA Yes No Yes No No IVK 66 34 51 18 15 15 10 8 17 41 11 13 55 18 22 13 22 Complete Partial Persisted Kralinger51 N/A N/A N/A N/A N/A N/A No difference between two groups 80% 20% 87% 13% Pre-op 400 m ¡ post-op 275 m Pre-op 233 m ¡ post-op 213 m N/A N/A N/A N/A N/A N/A 100% 0 100% 0 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Mean VA improved in both groups No difference between two groups 47% 53% 0 60% 40% 0 Pre-op 20/50 ¡ post-op 20/45 Pre-op 20/112 ¡ post-op 20/63 52. Until such time.9% 47. Intravitreal triamcinolone acetonide for diffuse diabetic macular oedema: 6-month results of a prospective controlled trial. Ferris FL III.4% 39% 16. as in the many others cited above. or a more favorable response to less invasive treatment modalities. A complication of diabetic retinopathy. vitrectomy.4 ¡ post-op 1. Mohamed S. THE JOURNAL OF RETINAL AND VITREOUS DISEASES ● 2008 ● VOLUME 28 ● NUMBER 3 Table 5.1% 43. 4. Vitrectomy Without vs With ILM Peeling 2 Edema (Exam/OCT) Study Kamura 34 Visual Acuity Improved Unchanged Worse Year ILM Peel No. Tsang CW. Acta Ophthalmol Scand 2006.1% 26.103:1796–1806. In this study.9% 0 Pre-op 1. Lam DS. internal limiting membrane. indicating that even ILM peeling does not uniformly improve visual outcomes despite favorable anatomic results.83 The serious limitations of this and all published reports is the lack of a control group. 2. Haouchine B. and may parallel results of preliminary surgical series with 22% spontaneous improvement and only 17% deterioration at 1 year in 107 eyes. irreversible ultra structural damage to Muller cells and ¨ their retinal processes after ILM peeling.1% 0 56. widespread acceptance. Decreasing efficacy of repeated intravitreal 3. surgical series populated by exclusively shorter durations may include eyes that had a more favorable natural history. Surv Ophthalmol 1984. a significant reduction in foveal thickness has commonly not led to improvement in visual acuity. we were unable to identify any such subgroup in the current study.6% 44.83 On the other hand. Audren F. Therefore. Key words: diabetic macular edema. Patz A. only a randomized. Chan CK. Erginay A. Lai TY. Photocoagulation for diabetic macular edema. not available. possibility. ILM internal limiting membrane.9 Pre-op 1. IVTA intravitreal Yamamoto50 2005 Patel55 Bahadir48 Bardak49 2006 2005 2006 Stefaniotou42 2004 Mochizuki37 2006 *No statistically significant difference between the two groups for all studies. Arch Ophthalmol 1985.84:624–630. References 1. Perhaps OCT will allow detection of more subtle preretinal traction. The large number of series evaluating the efficacy of vitrectomy (with or without ILM peeling) has yielded conflicting results suggesting vast gaps in our understanding of the mechanisms or which subgroups might benefit the most. but a natural history study reports results similar to surgical series. VA various cytokines such as vascular endothelial growth factor and others potentiating capillary permeability. Macular edema. randomized study found that the natural history is not uniformly bad.6% 55% 31% 14% 77% 8% 15% 27% 55% 18% visual acuity. et al.7% 3. Early Treatment Diabetic Retinopathy Study report number 1.31– 64 Aside from the infrequently encountered eye with evident posterior hyaloidal traction. Accordingly. OCT optical coherence tomography.81 Vitrectomy for DME has seemingly gained rapid. .3 ¡ post-op 0. when coupled with relief of tangential traction. it has been postulated that peeling of the ILM in chronic macular edema may help to remove the diffusion barrier and. The preliminary results of a planned prospective. Our results and others’ might be influenced by the chronic nature of the edema (mean of 22 months) and.28:452–461. macular edema. Shanmugam MP.

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