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      Pars Plana Vitrectomy with Internal Limiting Membrane Peeling Compared with Intravitreal Triamcinolone Injection in the Treatment of Diabetic Macular Edema

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          Abstract

          Aim: To compare the efficacy of pars plana vitrectomy (PPV) with internal limiting membrane (ILM) removal and intravitreal triamcinolone acetonide (IVTA) injection in patients with diabetic macular edema (DME). Methods: This study was a retrospective, comparative, interventional case study examining 14 patients (15 eyes in total) who underwent PPV and ILM removal (vitrectomy group), and 14 patients (14 eyes in total) who were treated with an IVTA injection (triamcinolone group). Main outcome measures were visual acuity and central macular thickness at 1, 3 and 6 months postoperatively. Results: Patients in the vitrectomy group had significantly decreased central macular thicknesses at 1, 3 and 6 months postoperatively (p = 0.001, p = 0.001 and p = 0.002, respectively). The improvement in visual acuity was not significant at 1 month, but it gradually became statistically significant at 3 and 6 months after surgery (p = 0.031 and p = 0.015, respectively). Compared with the triamcinolone group, the vitrectomy group showed a better visual acuity at 6 months after surgery (p = 0.025). Conclusions: PPV combined with ILM removal is a good therapeutic option for improving visual acuity and decreasing macular thickness in DME, and this treatment has a better long-term efficacy than a single IVTA injection.

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          The 14-year incidence of visual loss in a diabetic population.

          Marina Klein, S Moss, John Klein (1998)
          The purpose of the study was to estimate the 14-year incidence of visual loss in a diabetic population and to examine its relationship to potential risk factors. Cohort study. A population-based sample of younger onset diabetic persons diagnosed younger than 30 years of age and taking insulin (n = 880) were examined at baseline, 4 years, 10 years, and 14 years. Visual acuity (VA) as measured by the Early Treatment Diabetic Retinopathy Study protocol was performed. Visual impairment (VI), defined as a VA of 20/40 or worse in the better eye; blindness, defined as a VA of 20/200 or worse in the better eye; and doubling of the visual angle were measured. Cumulative 14-year incidences of VI, doubling of the visual angle, and blindness were 12.7%, 14.2%, and 2.4%, respectively. In univariate analyses, loss of vision as measured by doubling of the visual angle is associated with older age, longer duration of diabetes, higher glycosylated hemoglobin, higher systolic and diastolic blood pressure, presence of proteinuria, more pack-years smoked, presence of macular edema, and more severe retinopathy. In logistic regression analyses, incidence of doubling of the visual angle is associated independently with retinopathy (odds ratio [OR], 1.07; 95% confidence interval [CI], 1.03, 1.11 for each level), glycosylated hemoglobin (OR, 1.46; 95% CI, 1.28, 1.66 for each 1%), proteinuria (OR, 2.32; 95% CI, 1.39, 3.88 for presence), and age (OR, 1.45; 95% CI, 1.20, 1.75 for 10 years). In addition, a change in glycosylated hemoglobin from baseline to the 4-year examination is associated with loss of vision (OR, 1.15; 95% CI, 1.02, 1.30 for a 1% increase). Loss of vision continues to be significant in persons with diabetes. These results suggest that prevention of retinopathy through control of glycemia will have a beneficial effect on visual outcome.
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            Intraocular concentration and pharmacokinetics of triamcinolone acetonide after a single intravitreal injection.

            Lee B Peters, Weiguo Liu, Shree Singh … (2003)
            To describe the pharmacokinetics occurring after the direct injection of triamcinolone acetonide into the vitreous humor of humans. Interventional case series. Five patients who received a single 4-mg intravitreal injection of triamcinolone acetonide. An aqueous humor sample was obtained from 5 eyes via an anterior chamber paracentesis at days 1, 3, 10, 17, and 31 after injection. At each visit, visual acuity and intraocular pressure were measured and indirect ophthalmoscopy was performed. A fluorescein angiogram was carried out at day 10. Concentrations were determined using high performance liquid chromatography; pharmacokinetic analysis was carried out using PK Analyst, an iterative, nonlinear, weighted, least-squares regression program. Intraocular concentrations of triamcinolone were measured and population pharmacokinetic parameters were calculated. Pharmacokinetic data followed a two-compartment model. Peak aqueous humor concentrations ranged from 2151 to 7202 ng/ml, half-lives from 76 to 635 hours, and the integral of the area under the concentration-time curve (AUC(0-t)) from 231 to 1911 ng/h per milliliter. After a single intravitreal injection of triamcinolone, the mean elimination half-life was 18.6 days in nonvitrectomized patients. The half-life in a patient who had undergone a vitrectomy was shorter at 3.2 days. There was considerable intrasubject variation among peak concentration, AUC(0-t) values, and elimination half-lives. After intravitreal injection, measurable concentrations of triamcinolone would be expected to last for approximately 3 months (93 +/- 28 days) in the absence of a vitrectomy. Because triamcinolone pharmacokinetics were characterized only in elderly patients with macular edema, the results cannot be extrapolated to other patient populations.
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              Ocular oxygenation and the treatment of diabetic retinopathy.

              Einar Stefánsson (2015)
              Retinal photocoagulation and vitrectomy both reduce diabetic macular edema and neovascularization in diabetic retinopathy. We suggest that this clinical effect is based on the effect these treatment modalities have on retinal oxygenation, and we present a theory to explain why retinal photocoagulation and vitrectomy influence edema and neovascularization in diabetic and other ischemic retinopathies.
              Article 0 comments Cited 46 times – based on 0 reviews     Review now
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                Author and article information

                Journal
                Journal ID (publisher-id): OPH
                Journal ID (nlm-ta): Ophthalmologica
                Journal ID (doi): 10.1159/issn.0030-3755
                Title: Ophthalmologica
                Publisher: S. Karger AG
                ISSN (Print): 0030-3755
                ISSN (Electronic): 1423-0267
                Publication date Subscription-year: 2009
                Publication date (Print): January 2009
                Publication date (Electronic): 13 October 2008
                Volume: 223
                Issue: 1
                Pages: 17-23
                Affiliations
                Institute of Vision Research, Department of Ophthalmology, Yonsei University College of Medicine, Seoul, Korea
                Article
                Publisher ID: 161878 Other ID: Ophthalmologica 2009;223:17–23
                DOI: 10.1159/000161878
                PubMed ID: 18849632
                SO-VID: 07c1ce3a-8c07-4ee9-b0d1-eeecb1104745
                Copyright © © 2008 S. Karger AG, Basel
                License:

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                History
                Date received : 08 March 2007
                Date accepted : 06 September 2007
                Page count
                Figures: 4, Tables: 1, References: 20, Pages: 7
                Categories
                Subject: Original Paper

                ScienceOpen disciplines: Vision sciences,Ophthalmology & Optometry,Pathology
                Keywords: Vitrectomy,Diabetic macular edema,Triamcinolone acetonide
                Data availability:
                ScienceOpen disciplines: Vision sciences, Ophthalmology & Optometry, Pathology
                Keywords: Vitrectomy, Diabetic macular edema, Triamcinolone acetonide

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