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Pars Plana Vitrectomy for Diabetic Macular Oedema Eye (2006) 20, 674–680 & 2006 Nature Publishing Group All rights reserved 0950-222X/06 $30.00 www.nature.com/eye 1,2 1 1 2 CLINICAL STUDY Pars plana JI Patel , PG Hykin , M Schadt , V Luong , F Fitzke2 and ZJ Gregor1 vitrectomy for diabetic macular oedema: OCT and functional correlations Abstract Eye (2006) 20, 674–680. doi:10.1038/sj.eye.6701945; published online 21 October 2005 Purpose A prospective study to evaluate the macular structural and functional effects of Keywords: diabetes; macular oedema; pars pars plana vitrectomy (PPV) for persistent plana vitrectomy; OCT diffuse clinically significant macular oedema (CSMO). Method A total of 12 patients with persistent Introduction diffuse CSMO were recruited and underwent assessment including best-corrected visual Diabetes mellitus is the leading cause of acuity, fundus fluorescein angiography, optical blindness in the working population in the coherence tomography (OCT) and fine matrix developed world and diabetic macular oedema mapping (FMM) at baseline and over a period (DMO) accounts for 72% of registrable of a year poststandard three-port PPV. blindness among patients with diabetes Results The median baseline ETDRS letters mellitus.1 In all 9% of the diabetic population score for all 12 patients was 52 (range 41–63) develop oedema within one disc diameter (DD) while at 12 months it had increased to 65 of the fovea and 40% of those have central (range of 27–68), an improvement of two macular involvement.2 The natural history of complete ETDRS lines (P ¼ 0.037). Similarly, DMO is one of progressive visual loss with there was an improvement in the perifoveal more than 50% of patients losing two or more cone thresholds (P ¼ 0.02). The foveal lines of visual acuity within 2 years.3 thickening for all 12 patients ranged from a At present there are only two proven median of 183 to 751 lm (normal range 126– modalities of management: strict control of 1 Moorfields Eye Hospital, 180 lm) and the macular volume ranged from a systemic blood glucose and blood pressure has London, UK median of 2.13 to 6.42 mm3 (normal been shown to delay the onset and to reduce the o1.66 mm3). After surgery, both the median progression of diabetic retinopathy for both 2Department of Pathology, foveal thickness (from 334 to 280 lm) and 4,5 Institute of Ophthalmology, Type I and Type II diabetes mellitus. The London, UK median macular volume (from 3.24 to second is the timely use of photocoagulation of 2.61 mm3) demonstrated decreases over 12 the perifoveal retina.6 The results of the Early Correspondence: JI Patel, months (P ¼ 0.01). On baseline OCT, the Treatment Diabetic Retinopathy Study (ETDRS) Department of Pathology, patients fell into two anatomically distinct showed that laser treatment mostly stabilised Institute of Ophthalmology, groups: Group 1 (n ¼ 4) had a dome-shaped vision and reduced the risk of moderate visual 11-43 Bath St., EC1V 9EL thickened macula with a partial posterior London, UK loss by 50%. However, only 3% of the patients Tel: þ 44 207 608 6808; hyaloid separation and a significantly higher improved by three or more lines of vision by the Fax: þ 44 207 608 6862. foveal thickness and macular volume than end of that study. E-mail: jigs37@ Group 2 (n ¼ 8) which had a diffuse low- Lewis was the first to describe a positive hotmail.com elevation profile of the thickened macula effect of pars plana vitrectomy (PPV) on diabetic (P ¼ 0.007). patients who had a thickened and taut posterior Received: 23 August 2004 Conclusions In this prospective study of PPV Accepted: 15 April 2005 hyaloid membrane with traction on the macula. Published online: for persistent fovea-involving CSMO there There were improvements in both vision and 21 October 2005 was structural and functional improvement. resolution of macular oedema7 and the Vitrectomy for diabetic macular oedema JI Patel et al 675 accompanying shallow macular detachment thought to the computer software (Zeiss-Humphrey, Dublin, CA, develop secondary to the tractional forces.7 Recently, software version A5, using model OCT 2) included an reports of PPV performed on patients with an attached estimation of the foveal thickness and the macular but non-thickened posterior hyaloid and without volume, which is derived by an integration process of the ophthalmoscopic evidence of macular traction showed average retinal thickness of the six radial scans. improvement in the visual acuity and reduction of FMM is a psychophysical method of examination, macular oedema.8,9 However, most of the studies on which determines the cone thresholds in a 9 Â 9 degree patients with a nonthickened posterior hyaloid field centred on the point of fixation. A total of 100 points membrane and DMO were retrospective and variable in within this test field are analysed using a modified surgical technique, with some patients having cataract9 Humphrey field analyser. A three-dimensional or internal limiting membrane10 removed representation of photopic white stimulus thresholds simultaneously. (given as log units) can be generated from there data. The The aim of this prospective study was to determine the thresholds are a mean of the 100 points. The lower the clinical efficacy of PPV for patients with persistent and threshold, the better the overall cone function within the diffuse DMO in the presence of an attached but tested field. This psychophysical analysis of nonthickened posterior vitreous cortex. photoreceptor function has been used and validated in the assessment macular function in central serous retinopathy12 and age-related macular degeneration.13 Patients and methods Overlay of the central OCT field on the central 9 Â 9 Patients with persistent clinically significant macular degree field of the fine matrix map (after appropriate oedema (CSMO) despite previous macular laser, were scaling and adjustment) was performed to evaluate offered enrolment in this prospective study. A masked corresponding retinal thickness and the associated cone observer assessed the best-corrected visual acuity function, and the changes in these parameters after PPV. (BCVA) for both Snellen and ETDRS vision score. All All patients underwent standard three-port PPV with patients underwent dilated retinal examination, elevation and the removal of the posterior vitreous intravenous FFA, optical coherence tomography (using cortex, but with no peeling of the internal limiting OCT 2) and fine matrix mapping (FMM). The membrane. Fluid-SF6 gas exchange was performed if preoperative examinations were performed within a retinal breaks were found on the 3601 examination of the month of surgery to obtain the baseline clinical peripheral retina prior to the conclusion of the operation. parameters and then subsequently at 2, 6, 12 and 24, and Such breaks were treated with laser photocoagulation or 48 weeks postoperatively. cryotherapy. Subconjunctival injection of Betamethasone Inclusion criteria were (i) persistent diffuse CSMO and Cefuroxime was given at the conclusion of the involving the foveal centre of less than 2 years in operation. Patients were treated with topical Atropine duration (ii) previous treatment with macular laser and 1%, Dexamethasone and Chloramphenicol for 3 weeks (iii) ETDRS vision score of 59 to 35 (equivalent Snellen after the operation. visual acuity 6/15 to 6/60). Exclusion criteria were (i) All patients were recruited in accordance with the posterior vitreous detachment diagnosed by the presence Declaration of Helsinki and with the approval of the of the Weiss ring (ii) macular traction as evidenced by Ethics Committee of Moorfields Eye Hospital. retinal striae involving the foveal centre (iii) macular ischaemia as defined by an enlarged foveolar avascular Statistical analysis zone (FAZ41000 mm) or significant perifoveal capillary loss on fundus fluorescein angiography (FFA) and (iv) OCT and clinical parameters were analysed by unpaired coexistent retinal disease. Mann–Whitney U-test and a paired Wilcoxon test used OCT is a noninvasive, noncontact imaging modality for the appropriate comparison with the significance producing high-resolution cross-sectional tomographs of value taken at Po0.05. ocular tissue.11 It produces a two-dimensional false colour image of the back-scattered light from different Results layers of the retina analogous to ultrasonic B-scan imaging. The only difference is that optical reflectivity is Seven male and five female patients were enrolled in the measured. Axial resolution up to 14 mm is achievable. Six study. The average age of the patient was 63 years (range 6 mm diameter radial scans centred on the point of 46–72 years). All patients had type II diabetes mellitus of fixation were taken at each time point, assessed an average duration of 11 years (range 4–23 years). Four qualitatively, and analysed quantitatively using the were on oral medication; six were on insulin, only one retinal mapping software. Quantitative assessment using was on combined insulin and oral medication treatment, Eye Vitrectomy for diabetic macular oedema JI Patel et al 676 and one was controlled by diet alone. The average large central pocket of fluid within the retina (see HbA1c was 8% (range 5.8–9.9). Nine patients had Figure 2). Baseline median foveal thickness was 478 mm controlled systemic hypertension and one was on (range 472–751 mm) and macular volume was 3.9 mm3 lipid-lowering drugs. The patients suffered from no (range 3.74–6.42 mm3). Group 2 (n ¼ 8) had a diffuse other significant ocular conditions. All patients had low-elevation profile of the thickened macula with moderate nonproliferative diabetic retinopathy. All had reduced intraretinal reflectivity and multiple intraretinal fovea-involving macular oedema, which had been cysts and no signs of a focal posterior hyaloid separation present for an average of 15 months (range 12–18 (see Figure 2). Baseline median foveal thickness was months) and all were previously treated with macular 233 mm (range 198–374 mm) and macular volume was argon laser photocoagulation, on average three 2.7 mm3 (range 2.13–3.52 mm3).
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