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1. Surgical Management of Diabetic
Retinopathy
Thomas Aaberg Jr. M.D.
Retina Specialist of Michigan
Michigan State University

2. Management of complications
from Proliferative diabetic
retinopathy
 Pars plana vitrectomy is the procedure
of choice for vitreous hemorrhage and
tractional retinal detachment

3. Pars plana vitrectomy-
Indications
 Persistent vitreous hemorrhage
 Tractional/combined rhegmatogenous
retinal detachment
 Premacular hemorrhage
 Bridging retinal fibrosis
 Persistent diabetic macular edema

4. Pathogenesis Review:
Surgical Intervention for TRD
 Hypoxia and angiogenic
factors, eg. VEGF
 Neovascular and
fibrovascular proliferation
that extends from the
retina into the vitreous
cavity
 Cycle of proliferation and
regression along the
posterior margin of
capillary non-perfusion
Vitreous Surgery. In Michels RG, Wilkinson CP and Rice TA eds. Retinal Detachment. St. Louis, 1990, Mosby, p. 814

5. Pathogenesis Review:
Surgical Intervention for TRD
 Neovascular proliferation
usually begins:
 at the optic nerve
 along temporal
vascular arcades
 mid-periphery at the
posterior margin of
capillary non-
perfusion
Vitreous Surgery. In Michels RG, Wilkinson CP and Rice TA eds. Retinal Detachment. St. Louis, 1990, Mosby, p. 814

6. Pathogenesis Review:
Proliferative Diabetic Retinopathy
 Initially “bare”
 Later, fibrous tissue appears
 Vitreoretinal adhesions form
 Cycle of proliferation and
regression

7. Pathogenesis Review:
Surgical Intervention for TRD
 Growth of fibrovascular tissue is
dependent on posterior vitreous surface
 Changes in vitreous occur, often resulting
in partial posterior vitreous detachment
 Vitreous typically remains attached at
anterior retina/vitreous base and at each
area of fibrovascular proliferation
Vitreous Surgery. In Michels RG, Wilkinson CP and Rice TA eds. Retinal Detachment. St. Louis, 1990, Mosby, p. 815

8. Pathogenesis Review:
Surgical Intervention for TRD
 Contraction of
fibrovascular tissue
growing along posterior
vitreous surface can cause
vitreous changes and
antero-posterior traction.
 In the absence of vitreous
separation, widespread
adhesions to the retinal
surface may develop
Vitreous Surgery. In Michels RG, Wilkinson CP and Rice TA eds. Retinal Detachment. St. Louis, 1990, Mosby, p. 816

9. Pathogenesis Review:
Surgical Intervention for TRD
 Contraction forces may
lead to:
 Hemorrhage into vitreous
gel or preretinal space
 Tractional retinal
detachment (TRD)
 Distortion of retina/macula
 Antero-posterior and
tangential traction
 Traction on the optic nerve
 Retinal tears
Vitreous Surgery. In Michels RG, Wilkinson CP and Rice TA eds. Retinal Detachment. St. Louis, 1990, Mosby, p. 816

12. Surgical Management
A review of the past,
And where we are today.

13. Surgical Intervention for TRD
Purpose
Reverse pre-existing complications
causing visual loss
Alter course of retinopathy and remove
posterior vitreous surface
Vitreous Surgery. In Michels RG, Wilkinson CP and Rice TA eds. Retinal Detachment. St. Louis, 1990, Mosby, p. 816

14. Surgical Intervention for TRD
 Posterior vitreous
surface is of great
importance in
pathogenesis and
complications of
proliferative
diabetic retinopathy
and must be
addressed during
vitreous surgery
Vitreous Surgery. In Michels RG, Wilkinson CP and Rice TA eds. Retinal Detachment. St. Louis, 1990, Mosby, p. 816

15. Surgical Intervention for TRD
 Surgical objectives
Remove visually significant opacities
Excise posterior hyaloid
Remove and/or segment preretinal or
epiretinal fibrovascular tissue
Identify & treat retinal breaks
Hemostasis
Panretinal photocoagulation
Tamponade as needed
Vitreous Surgery. In Michels RG, Wilkinson CP and Rice TA eds. Retinal Detachment. St. Louis, 1990, Mosby, p. 816

16. DDiabetic
RRetinopathy
VVitrectomy
SStudy
A MultiA Multi--Center Collaborative Clinical TrialCenter Collaborative Clinical Trial
Supported by Contracts fromSupported by Contracts from
The National Eye InstituteThe National Eye Institute
PortlandPortland
San FranciscoSan Francisco
Los AngelesLos Angeles
MinneapolisMinneapolis
MadisonMadison
ChicagoChicago
MilwaukeeMilwaukee
DetroitDetroit
AlbanyAlbany
BostonBoston
New YorkNew York
PhiladelphiaPhiladelphia
BaltimoreBaltimore
DurhamDurham
AtlantaAtlanta
MiamiMiami

17.  More rapid recovery of useful vision (important if fellow eye
has poor vision)
 Greater chance for recovery of good vision (at least Type I DM
who were younger and had more severe PDR)
 Suggestive increase in frequency of NLP in Type II and mixed
DM groups (older patients with less PDR)
Early Vitrectomy in Eyes with
Recent Severe Diabetic Vitreous
Hemorrhage

18. Diabetic Retinopathy
Vitrectomy Study
 Eyes (n = 370) with fibrovascular
proliferation and 20/400 or better VA
Results: 20/40 or better VA at 4 years
Early surgery: 44% eyes
Deferred surgery: 28% eyes
Early Vitrectomy for Severe Proliferative Diabetic Retinopathy in Eyes with Useful Vision. Results of a Randomized Trial-
-. Diabetic Retinopathy Vitrectomy Study (DRVS) report #3. Ophthalmol 1988; 95(10):1307-1320

19. Results of Vitrectomy for
diabetic TRD involving macula
 Improved VA: 26% - 72% cases
Vitreous Surgery. In Michels RG, Wilkinson CP and Rice TA eds. Retinal Detachment. St. Louis, 1990, Mosby, p. 824-825

20. Results of Vitrectomy for combined
diabetic TRD and rhegmatogenous
detachment
 Retinal reattachment: 80%
 Improved Vision: 50%
 Rates of success can vary
based on patient
population, pathology and
access to health care
Vitreous Surgery. In Michels RG, Wilkinson CP and Rice TA eds. Retinal Detachment. St. Louis, 1990, Mosby, p. 825
Photo courtesy of Edgar L. Thomas, MD

21. Diabetic Vitrectomy: Advanced
Surgical Techniques

22. Step 1: Pre-operative Care

23. Advanced Diabetic Vitrectomy
Begins Pre-operatively
 Maximize systemic health/stability
 Concentrate on renal status
 Work with primary care physician,
endocrinologist, nephrologist
 Properly educate patient
 Pathophysiology
 Extent of disease
 Proper patient expectations

24. Immediate Pre-Operative
 Anti-VEGF … Yes or No
 Literature supporting
both pro and con
 Personally I use IF:
 I know the patient will be
compliant
 I know the surgical case is
a GO
 There is active NV not just
traction or hemorrhage.

25. Why be concerned about anti-
VEGF use?
 Immediate concern:
 Delayed surgery may
lead to progressive
severe vitreoretinal
contraction
 Longer term concern:
 Rebound proliferation
once anti-VEGF effect
dissipates.

26. Step 2: Surgical Planning
Game changing advances in
surgical instrumentation.

27. Surgical Planning/Decisions
 Anesthesia: General vs Local
 Gauge: 20 vs 23 vs 25 vs 27
 Lens disposition
 Pseudophakic
 Phakic
 Unencumbered view of pathology
 Compromises view
 Keep or remove the lens with or without an IOL
 Bimanual versus “uni”-manual approach

28. Chosen Surgical Gauge was largely
dictated by number of available
instruments
 Vitrectomy probes
High speed cutters
Different edge profiles
20 gauge
20 gauge
25 gauge
25 gauge

29. Advances in Surgical Instrumentation
20 gauge
 Forceps

30. Advances in Surgical Instrumentation
20 gauge
Scissors

31. Advances in Surgical Instrumentation
20 gauge
 Illuminated instruments

32. Currently nearly all instruments are
available in 25 and 23 gauges
Photos courtesy of E.Thomas, MD and Alcon
25 gauge - system

33. Advances in Surgical Instrumentation
25 gauge - system
Vitrectomy cutter
Trochar canula inserter
Canula
InstrumentsPhotos courtesy of E.Thomas, MD and Alcon

34. Advances in Surgical
Instrumentation
25 gauge
Forceps
Scissors
Picks

35. Illuminated instrumentation and
chandeliers … a critical advance
 20 gauge chandelier and set-up
 Illuminates one area preferentially
Photos courtesy of Synergetics and James Andrews

36. Illuminated instrumentation and
chandeliers … a critical advance
Photos courtesy of Synergetics and James Andrews
29-gauge chandelier and Xenon light source

37. Another critical surgical advance:
Perfluorocarbon Liquid
 Properties
 Non-toxic
 Clear liquid
 High density
 Low viscosity; easy
to inject and remove
 Visualize liquid
interface
 Volatility

38. Perfluorocarbon Liquid:
The Third Hand
 Benefits
 Keep heme off
macular region
 Assist in dissection
and removal of
posterior hyaloid
 Stabilize the retina
during membrane
dissection and
delamination

39. Perfluorocarbon Liquid:
The Third Hand
 Benefits
 Identify residual
posterior hyaloid
and membranes
 Drain subretinal
fluid through
peripheral break
 Allow for
controlled
retinotomies

40. Perfluorocarbon Liquid:
The Third Hand
 Complications
 Subretinal PFC may pass through posterior
breaks with traction
 Residual PFC at end of surgery
more common in hemorrhages

41. Advances in Surgical Instrumentation:
Wide Angle Viewing
 Contact
 AVI
 Volk
 Noncontact
 BIOM
 Merlin

42. Advances in Surgical Instrumentation
Wide Angle Viewing
 Benefits
 Improved panoramic visualization
 More easily visualize extent of tractional forces
 Improved management of peripheral retinal
pathology
 Bimanual surgery
 Enhances phakic fluid air exchange and
placement of scatter laser treatment

43. Step 3: Surgical Techniques

44. Single Instrument Vitrectomy

45. Bimanual Surgery
 Endo-illumination by chandelier
 Single chandelier
 Dual chandelier
 Illuminated infusion cannula
 Illuminated instruments

46. Surgical Intervention for TRD
 Surgical Techniques
Vitrectomy
Remove core vitreous
Incise posterior vitreous surface
Relieve A-P traction
Vitreous Surgery. In Michels RG,
Wilkinson CP and Rice TA eds. Retinal
Detachment. St. Louis, 1990, Mosby, p.
816-817

47. Surgical Techniques for surface
membranes
Segmentation
Divide fibrovascular tissue
Vitreous Surgery. In Michels RG, Wilkinson CP
and Rice TA eds. Retinal Detachment. St. Louis,
1990, Mosby, p. 816-824

48. Surgical Techniques for surface
membranes
 En bloc
Use some posterior vitreous A-P traction
to elevate edge of fibrovascular tissue
Diagrams from Gardner
TW and Blankenship GW.
Proliferative diabetic
retinopathy: principles
and techniques of surgical
treatment. In Ryan SJ ed.
Retina, Bert Glaser, ed.
Vol 3 Surgical Retina. St.
Louis, 1994, Mosby, p.
2420-2421

49. Surgical Techniques for surface
membranes
 Modified En Bloc
Delamination
 After releasing
pathology from
the vitreous base,
use an instrument
to induce A-P
traction and create
a cleavage plane.

50. Surgical Techniques for surface
membranes
 Modified En Bloc
Delamination
 Identify cleavage plane
 Scissors to transect
fibrovascular bridges
 Hemostasis
 Endodiathermy or
bipolar diathermy
 PRP
 Tamponade as needed

51. Hemostasis
 Critical in the diabetic
patient
 Fibrin deposition
 Secondary membranes
 Immediate post-
operative vitreous
hemorrhages
 Tactics
 Raise intraocular
pressure
 Intraocular diathermy
 Intraocular Thrombin

52. Surgical Intervention for TRD
 First-Is it necessary?
 Break
 No-breaks
 Second-Which
agent?
 Air
 SF6
 C3F8
 Silicone oil
 Monocular
 Aphakia

53. Tamponade
 Factors relevant to
tamponade agent
 Extent of pathology
 Patient
compliance/physical
abilities
 Lens Status
 Monocular vs
Binocular
 Travel

54. Surgical intervention for TRD
 Major Complications
Retinal tears
Retinal detachment
PVR
Cataract
Endophthalmitis
Vitreous Surgery. In Michels RG, Wilkinson CP and Rice TA eds. Retinal Detachment. St. Louis, 1990, Mosby, p. 825

56. Management of Tractional
Retinal Detachment
Summary
 Tractional Retinal Detachment
 Pathogenesis
 Surgical intervention
 Surgical objectives/techniques
 Progress in instrumentation
 Perfluorocarbon liquids
 Wide angle viewing
 High speed vitrectomy
 25 gauge - sutureless
 Pharmacotherapeutic interventions
 Plasmin
 Vitrase

57. Premacular hemorrhage
Pre-Operative Vision = CF

58. Post vitrectomy
Vision = 20/30