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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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          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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          Most cited references 10

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

          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.

            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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              Vitrectomy for diffuse diabetic macular edema associated with a taut premacular posterior hyaloid.

              To evaluate the role of vitrectomy in eyes with diffuse diabetic macular edema associated with a taut posterior hyaloid. Records of 55 eyes of 50 patients with diabetic retinopathy and diffuse clinically significant diabetic macular edema who underwent vitrectomy with stripping of the premacular posterior hyaloid were reviewed. In all 55 eyes, diffuse diabetic macular edema was present on contact lens examination and confirmed with fluorescein angiography. On fundus examination, the premacular posterior hyaloid was attached and appeared taut. The mean preoperative best-corrected visual acuity was 20/160, and the mean final best-corrected visual acuity was 20/80 (P <.0001, Wilcoxon signed rank test), with 27 (49.1%) of the 55 eyes demonstrating improvement in best-corrected visual acuity of 2 or more lines. Fifty-two (94.5%) of the 55 vitrectomized eyes showed improvement in clinically significant macular edema and in 45 eyes (81.8%) the macular edema resolved completely during a mean period of 4.5 months (range, 1 to 13 months). Eyes with macular ischemia and preoperative best-corrected visual acuity of 20/200 or less tended to respond less favorably to vitrectomy than eyes lacking these characteristics. All eyes had at least 6 months of follow-up after surgery, with a mean follow-up of 23.2 months. In eyes with persistent diffuse diabetic macular edema with a taut premacular posterior hyaloid face unresponsive to laser therapy, vitrectomy with removal of the posterior hyaloid appears to be beneficial in some cases. Careful selection of eyes with favorable preoperative clinical characteristics may improve surgical outcomes.

                Author and article information

                S. Karger AG
                January 2009
                13 October 2008
                : 223
                : 1
                : 17-23
                Institute of Vision Research, Department of Ophthalmology, Yonsei University College of Medicine, Seoul, Korea
                161878 Ophthalmologica 2009;223:17–23
                © 2008 S. Karger AG, Basel

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                Page count
                Figures: 4, Tables: 1, References: 20, Pages: 7
                Original Paper


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