45

QUESTION

WHEN SHOULD A PATIENT WITH DIABETIC RETINOPATHY BE CONSIDERED FOR A VITRECTOMY?

Ronald C. Gentile MD, FACS, FASRS
Alexander Barash, MD

Diabetic retinopathy is the leading cause of blindness in working-aged persons in the United States.¹ Diabetic vitrectomy is reserved for eyes with complications of diabetic retinopathy not amenable to intravitreal injection or laser. Even among compliant patients with frequent ophthalmic exams and timely scatter panretinal laser photocoagulation, vitrectomy still becomes necessary in at least 5% of patients.² The surgical goal of a diabetic vitrectomy is to clear the vitreous of opacities, release and remove tractional elements from the retinal surface, promote attachment or reattach any detached retina, and complete panretinal photocoagulation with or without the addition of intravitreal pharmacological agents.

The 2 predominant classic indications for diabetic vitrectomy, nonclearing vitreous hemorrhage and tractional retinal detachment involving the macula, have remained the same since the results of the Diabetic Retinopathy Vitrectomy Study were published in the 1980s.

We have divided indications for diabetic vitrectomy into 5 broad categories (Table 45-1). These categories include (A) retinal detachment, (B) hemorrhage, (C) severe retinal neovascularization, (D) macular pathology, and (E) postvitrectomy. As it is not uncommon for eyes to have more than one indication for diabetic vitrectomy, a sixth category was added to include F. Combinations of A to E. Most indications are for complications of proliferative diabetic retinopathy (PDR) with a small percentage due to complications of nonproliferative diabetic retinopathy.

Tractional retinal detachment (Figure 45-1) involving or threatening the macula is one of the classic indications for diabetic vitrectomy. This usually occurs when retinal neovascularization develops along the vascular arcades with multiple epicenters, becomes fibrotic, and contracts causing the underlying retina to elevate and detach. This can occur with or without a partial posterior vitreous detachment (PVD). Tractional retinal detachment not involving the macula is not an indication for surgery because it can remain stable. This is especially true when the retinal neovascular component is inactive and fibrotic, most often seen after full prior-panretinal laser photocoagulation has been performed. It is important to note that intravitreal injections of anti-vascular endothelial growth factor (anti-VEGF) medications are to be used with caution in eyes with severe PDR especially if there is a tractional detachment near the macula, as they may cause progression of the tractional detachment. Tractional retinal detachments precipitated by an intravitreal injection of anti-VEGF generally occur 2 weeks after the injection, but can range from 3 to 21 days.3 When using preoperative intravitreal anti-VEGF agents before a diabetic vitrectomy with active neovascularization, some authors recommend it be given no more than 5 days preoperatively to avoid progression of the detachment.⁴

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