Pars Plana Vitrectomy and Combination Therapy Pars Plana Vitrectomy, Intravitreal Triamcinolon Acetonid and Macular Lasercoagulation – One Year Results
Authors:
J. Štefaničková 1; P. Strmeň 1; K. Vavrová 1; L. Mrózová 2; V. Krásnik 1
Authors‘ workplace:
Klinika oftalmológie LFUK a UNB Bratislava, prednosta doc. MUDr. Vladimír Krásnik, PhD.
1; Caldera, s. r. o., vedúci Mgr. Miroslav Helbich, PhD.
2
Published in:
Čes. a slov. Oftal., 68, 2012, No. 5, p. 180-188
Category:
Original Article
Overview
Purpose:
To compare anatomic and functional results of pars plana vitrectomy with MLI peeling (group PPV) and pars plana vitrectomy with MLI peeling, intravitreal triamcinolon acetonide 4 mg and macular lasercoagulation (group PPV + TRIAM) in eyes with diffuse diabetic macular edema (DEM).
Methods:
In the group PPV eyes underwent PPV with MLI peeling and in the group PPV + TRIAM, PPV with MLI peeling, intravitreal triamcinolon acetonide 4 mg was performed at the end of surgery and macular lasercoagulation 3 weeks after surgery. Best corrected visual acuity (BCVA), central macular thickness (CMT) and macular volume were recorded before, 1, 3, 6 and 12 months after vitrectomy.
Results:
Sixty – eight eyes from 59 subjects with DEM non responsive to lasercoagulation or with vitreomacular traction were enrolled, the group PPV 35 eyes and the group PPV + TRIAM 33 eyes. In the group PPV before and 1, 3, 6 a 12 months after surgery mean BCVA were 0,22; 0,21; 0,28; 0,32; 0,30, mean CMT were 497,69 μm; 400,89 μm; 356,46 μm; 346,89 μm; 319,49 μm and mean macular volume were 11,48 mm3; 9,82 mm3; 9,28 mm3; 9,07 mm3, 8,83 mm3. In the group PPV + TRIAM mean BCVA were 0,18; 0,16; 0,23; 0,26; 0,26, mean CMT were 447,82 μm; 276,03 μm; 266,27 μm; 268,36 μm; 251,15 μm, mean macular volume were 10,71 mm3; 8,03 mm3; 8,28 mm3; 7,96 mm3; 7,66 mm3. In both groups statistical significant improvement in BCVA were observed from month 3 (p = 0.0013), in CMT and macular volume from month 1 (< 0.001). To compare both groups, in the group PPV + TRIAM changes in CMT and macular volume in month 1 after combination therapy from baseline were statistical significant, but without statistical significant, change in BCVA (p = 0.229). The major complications after surgery were an elevation of intraocular pressure and cataract surgery, more often in the group PPV + TRIAM (p = 0.153, p = 0.056).
Conclusion:
Both surgical technics are effective in the treatment of DEM. Combination therapy PPV, triamcinolon acetonide 4mg and macular lasercoagulation is associated with higher number of complications after surgery (elevation of intraocular pressure and cataract surgery).
Key words:
diabetic macular edema, pars plana vitrectomy, combination therapy
Sources
1. Antonetti, DA., Barbera, AJ., Hollinger, LA. et al.: Vascular endothelial growth factor induces rapid phosphorylation of tight junction proteins occludin and zonula occluden 1. A potential mechanismus for vascular permeability in diabetic retinopathy and tumors. J Biol Chem., 274, 1999; 33: 23463–7.
2. Avci, R., Kaderli, B., Avci, B., et al: Pars plana vitrectomy and removal of the internal limitng membrane in the treatment of chronic macular edema. Graefes Arch Clin Exp Ophthalmol, 242; 2004: 845–852.
3. Beer, PM., Bakri, SJ., Singh, RJ. et al.: Intraocular concentrations and pharmacocinetics of triamcinolone acetonide after a single intravitreal injections. Ophthalmology, 110; 2003: 681–686.
4. Bonini–Filho, MA., Jorge, R., Barbosa, JC. et al.: Intravitreal injection versus sub–Tenons infusion of triamcinolone acetonide for refractory diabetic macular edema: a randomized clinical trial. Invest Ophthalmol Vis Sci, 46; 2005: 3845–3849.
5. Chieh, JJ., Roth, DB., Liu, M. et al.: Intravitreal triamcinolone acetonide for diabetic macular edema. Retina 25; 2005: 828–834.
6. Dillinger, P., Mester, U.: Vitrectomy with removal of the internal limiting membrane in chronic diabetic macular oedema. Graefes Arch Clin Exp Ophthalmol, 242, 2004, 630–637.
7. Ducournau, D., Ducournau, Y.: A closer look at the ILM. Retinal Physician supplementum, July/August, 2008: 4–15.
8. Early Treatment of Diabetic Retinopathy Study Research Group. Photocoagulation for diabetic macular edema. Early Treatment Diabetic Retinopathy Study report number 1. Graefes Arch Clin Exp Ophthalmol, 103; 1985: 1796–1806.
9. Gandorfer, A., Messmer, E., Ulbig, MW. et al.: Resolution of diabetic macular edema after surgical removal of the posterior hyaloid and the inner limiting membrane. Retina, 20, 2000, 123–133.
10. Gaucher, D., Tadayoni, R., Erginay, A. et al.: Optical coherence tomography assessment of the vitreoretinal relationship in diabetic macular edema. Am J Ophthalmol, 139; 2005: 807–813.
11. Haller JA., Qin H., Apte RS. et al.: Vitrectomy outcomes in eyes with diabetic macular edema and vitreomacular traction. Ophthalmology, 117; 2010: 1087–1093.
12. Harbour, JW., Smiddy, WE., Flynn, Jr. HW. et al.: Vitrectomy for diabetic associated with a thickened and taut posterior hyaloid membrane. Am J Ophthalmol, 121; 1996: 405–413.
13. Holekamp, NM., Shui, YB., Beebe, DC. et al.: Vitrectomy surgery increases oxygen exposure to the lens: a possible mechanism for nuclear cataract formation. Am J Ophthalmol, 139; 2005: 302–310.
14. Jahn, CE., Topfner, L., von Schutz, K.et al.: Improvement of visual acuity in eyes with diabetic macular edema after treatment with pars plana vitrectomy. Ophthalmologica, 218; 2004: 378–384.
15. Jonas, JB.: Intravitreal triamcinolone acetonide for diabetic retinopathy. Dev Ophthalmol. Basel, Karger, 2007; vol. 39: 96–110.
16. Kang SW., Park SC., Kang JH.: Triple therapy of vitrectomy intravitreal triamcinolone and macular laser photocoagulation for intractible diabetic macular edema. Am J Ophthalmol 144; 2007: 878–885.
17. La Heij, EC., Hendrikse, F., Kessels, AG. et al.: Vitrectomy results in diabetic macular edema without evident vitreomacular traction. Graefes Arch Clin Exp Ophthalmol, 239; 2001: 264–270.
18. Larrson, J., Zhu, M., Sutter, F. et al.: Relation between reduction of foveal thickness and visual acuity in diabetic macular edema treated with intravitreal triamcinolone. Am J Ophthalmol, 139; 2005: 802–806.
19. Lee, GW., Ahn, AK., Park, YG.: Intravitreal triamcinolone reduces the morphologic changes of ciliary body after pars plana vitrectomy for retinal vascular diseases. Am J Ophthalmol, 145; 2008: 1037–1044.
20. Lewis, H., Abrams, GW., Blumenkraz, MS. et al.: Vitrectomy for diabetic macular traction and edema associated with posterior hyaloid traction. Ophthalmology, 99; 1992: 753–759.
21. Maeda, N., Tano, Y.: Intraocular oxygen tension in eyes with proliferative diabetic retinopathy with and without vitreous. Graefes. Arch. Clin. Exp. Ophthalmol., 234 (Suppl I); 1996: S66–S69.
22. Mayer, C.: Current treatment approaches in diabetic macular edema. Ophthalmologica, 221; 2007: 118–131.
23. Nguyen, QD., Shah, SM., Van Anden, E. et al.: Supplemental oxygen improves diabetic macular edema: a pilot study. Invest Opthalmol Vis Sci, 45; 2004: 617–624.
24. Pendergast, SD., Hassan, TS., Williams, GA. et al.: Vitrectomy for diffuse diabetic macular edema associated with a taut premacular posterior hyaloid. Am J Opthalmol, 130; 2000: 178–186.
25. Sebag, J., Buckingham, B., Charles, MA. et al.: Biochemical abnormalities of vitreous in humans with proliferative diabetic retinopathy. Graefes Arch Clin Exp Ophthalmol, 110; 1992: 1472–1476.
26. Sebag, J.: Vitreous anatomy and vitreomacular interface. Boston, Butterworth–Heinemann, 1998: s. 1–23.
27. Shah, SP., Patel, M., Thomas, D., et al.: Factors predicting outcome of vitrectomy for diabetic maculatr edema: results of prospective study. Br J Ophthalmol, 90; 2006: 33–36.
28. Steffanson, E.: Physiology of vitreous surgery. Graefes Arch Clin. Exp. Opthalmol., 247; 2009: 147–163.
29. Steffanson, E.: The therapeutic effects of retinal laser treatment and vitrectomy: a theory based on oxygen and vascular physiology. Acta Ophthalmol Scand, 79; 2001: 435–440.
30. Stolba, U., Binder, S., Gruber, D. et al.: Vitrectomy for persistent diffuse diabetic macular edema. Am J Ophthalmol, 140; 2005: 295–301.
31. Tachi, N., Ogino, N.: Vitrectomy for diffuse macular edema in cases of diabetic retinopathy. Am J Ophthalmol, 122; 1996: 258–260.
32. Yamamoto, T., Akabane, N., Takeuchi, S.: Vitrectomy for diabetic macular edema: The role of posterior vitreous detachment and epimacular membrane. Am J Ophthalmol, 132; 2001: 369–377.
33. Yanyali, A., Nohatcu, AG., Horozoglu, F. et al.: Modified grid laser photocoagulation versus pars plana vitrectomy with internal limiting membrane removal in diabetic macular edema. Am J Ophthalmol, 139; 2005: 795–801.
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