{"id":1633,"date":"2019-06-04T09:18:24","date_gmt":"2019-06-04T07:18:24","guid":{"rendered":"https:\/\/magenta-gull-175109.hostingersite.com\/cheirourgikes-prosengiseis-gia-ti-diacheirisi-tis-paragogikis-diavitikis-amfivlistroeidopatheias\/"},"modified":"2019-06-04T09:18:24","modified_gmt":"2019-06-04T07:18:24","slug":"cheirourgikes-prosengiseis-gia-ti-diacheirisi-tis-paragogikis-diavitikis-amfivlistroeidopatheias","status":"publish","type":"post","link":"https:\/\/myretina.gr\/en\/cheirourgikes-prosengiseis-gia-ti-diacheirisi-tis-paragogikis-diavitikis-amfivlistroeidopatheias\/","title":{"rendered":"Surgical approaches for the management of productive diabetic retinopathy"},"content":{"rendered":"

Diabetic retinopathy<\/strong><\/p>\n

\u0397 diabetic retinopathy (diabetic retinopathy)<\/strong> is the most serious of the diabetic eye diseases. It causes severe damage to the blood vessels that supply nutrients to the retina.<\/p>\n

These lesions result in bleeding, tissue necrosis and neovessel formation. Juvenile diabetes in our time is quite prevalent. It is very important for diabetics to regularly check their blood sugar levels.<\/p>\n

Hyalonectomy<\/strong><\/p>\n

\u0397 Hyalonectomy (vitrectomy)<\/strong> is a surgical procedure performed to treat diseases of the retina, macula and vitreous. During vitrectomy, the vitreous is removed and replaced with fluid produced postoperatively by the eye itself. With vitrectomy, we restore the normal anatomy of the retina and treat pre-existing damage. We also improve patients' vision by removing blood and vitreous opacities that interfere with the focusing of light on the retina.<\/p>\n

In the following article, we can look at surgical approaches to the management of productive diabetic retinopathy.<\/strong><\/p>\n

Significant results can be achieved with proper preoperative planning.<\/strong><\/p>\n

The role of vitrectomy in the management of productive diabetic retinopathy is complex and may include many of the following goals: removal of significant vitreous opacity, release of anterior or posterior traction, removal of multiple fibrovascular elements, and use of intra-lacer photocoagulation. In this article,some important information that should be considered when planning the surgical management of patients with productive diabetic retinopathy is mentioned.<\/p>\n

WHEN DOES THE OPERATING ROOM GET DRESSED?;<\/strong><\/p>\n

The management and treatment of productive diabetic retinopathy is often a difficult challenge. However, the techniques, technology and science of vitreoretinal surgery are constantly advancing, thanks to improvements in surgical tools, imaging and sophisticated techniques. As always, careful preoperative planning is the key to successful surgery.<\/p>\n

Vitreous haemorrhage with opacity<\/strong><\/p>\n

Vitreous hemorrhage is the most common complication of productive diabetic retinopathy and surgery is indicated for patients with reduced visual acuity due to vitreous hemorrhage with blurring. In 1985, investigators from the Diabetic Retinopathy Study Group (DRVS) randomly assigned patients with new severe vitreous hemorrhage (visual acuity 1\/40 or worse) to early (12 months) vitrectomy. They determined that early vitrectomy was particularly beneficial for patients with type 1 diabetes. Since then, practice patterns have developed, with most surgeons preferring to intervene earlier than 6 months in any patient with severe vitreous hemorrhage with opacity. In the era of very thin 25\/27 gauge vitrectomy instruments where surgical trauma is even less, the waiting time for absorption of bleeding is limited to one to two months if there is not the slightest indication of visual improvement.<\/p>\n

In our practice, we usually monitor a new vitreous hemorrhage for at least 2 months, then schedule a vitrectomy if there are no signs of significant clearance. We decide to proceed with early intervention in patients with bilateral visual loss, neovascularization of the iris, inadequate prior total retinal photocoagulation, or with certain anatomic factors favoring surgery (e.g., dense hemorrhage or coexisting retinal detachment that threatens the macula). B-scan ultrasonography should be performed preoperatively to assess the extent of vitreous detachment and to look for areas of vitreous traction.<\/p>\n

In case of recurrent vitreous hemorrhage associated with prolonged vision loss, surgery may be recommended without the same follow-up period. Recurrent vitreous hemorrhages may occur even in patients with controlled diabetic retinopathy, and examination of the fluroangiography may be useful in assessing the degree of disease and the need for additional retinal photocoagulation.<\/p>\n

The patient's preference for early visual rehabilitation or postponement of surgery should also influence the final decision for surgery. If the patient's systemic diabetic condition is poorly controlled, we may choose to stabilize the patient's health status with medication before recommending surgery.<\/p>\n

Complications due to traction<\/strong><\/p>\n

Another critical finding from the Diabetic Retinopathy Study Group (DRVS) was the recognition of a trend favoring early surgical intervention as the severity of neovascularization increases, particularly in subgroups of eyes with severe and very severe presence of multiple fibrovascular elements. This makes sense empirically, as more mature neovascular membranes often contribute to the development of traction complications.<\/p>\n

Multiple fibrovascular elements may coexist with retinal detachment or retinal tears. An attractive retinal detachment that involves or threatens the macula warrants early surgery, whereas a peripheral retinal detachment that does not threaten the macula can be safely monitored. Combined retinal and retinal detachments should undergo immediate surgery, even if they do not involve the macula, because of the risk of rapid deterioration.<\/p>\n

Vitrectomy may also be indicated for other complications due to diabetic retinopathy traction, including vitreoretinal traction and full-thickness macular hole. Epiretinal retinal membranes (ERMs) are commonly encountered in patients with productive diabetic retinopathy and traction in the macula that can lead to metamorphopsia or can exacerbate diabetic macular edema, causing a decrease in visual acuity. Simultaneous removal of the inner aphoretinal membrane may be considered in some cases to limit the extensive traction associated with diabetic macular edema or the overlying epiretinal membrane.<\/p>\n

SECRETS FOR SUCCESSFUL SURGERY IN PATIENTS WITH PRODUCTIVE DIABETIC RETINOPATHY: PREOPERATIVE PLANNING<\/strong><\/p>\n

Planning and preparation for surgery for patients with productive diabetic retinopathy involves assessing the patient's general health, providing advice and consent for surgery, and arranging drug therapy. Before we begin surgery, it is also important to consider the tools and techniques needed to achieve the goals of surgery for patients with productive diabetic retinopathy and to ensure that the team in the operating room is prepared to provide the equipment needed.<\/p>\n

Systemic condition of patients<\/strong><\/p>\n

Diabetes is a systemic vascular disease that is associated with many complications in our body, including myocardial infarction and stroke. The estimated 5-year survival of patients undergoing diabetic vitrectomy is 68%. To minimize the likelihood of arterial thromboembolic events during the peri-operative period, glycemic index, blood pressure and cholesterol levels should be improved before surgery. Pre-operative evaluation by an anaesthesiologist should be performed several days before surgery. Many patients with productive diabetic retinopathy have significant cardiovascular disease and should remain on anticoagulant and antiplatelet medications. For these patients, perivolumic or under tenonium treatment may be administered to mitigate the risk of retinal hemorrhage. The risk of intraoperative or postoperative vitreous hemorrhage is not significantly increased with continuation of anticoagulant and antiplatelet agents during the perioperative period.<\/p>\n

Expectations of patients<\/strong><\/p>\n

It is difficult to predict the improvement in a patient's visual acuity before surgery, especially when fundus imaging is limited by media opacity. Preoperatively, anatomic segments via optical coherence tomography (OCT), such as the medial aphoretic membrane and the integrity of the ellipsoidal zone, can help predict postoperative visual acuity. However, other factors such as ischemic optic neuropathy, glaucoma and ischemic macular degeneration may limit the improvement in visual acuity. Informing the patient about the complexity and unpredictability of diabetic surgery is important to set realistic expectations.<\/p>\n

Treatment with medicines<\/strong><\/p>\n

The administration of a pharmaceutical agent may help improve diabetic retinopathy. This strategy may be pursued preoperatively to minimize the risk of intraoperative bleeding and to alter the anatomic planes encountered during surgery.<\/p>\n

Anti-angiogenic factors<\/strong><\/p>\n

Preoperative injection ofAVASTIN (bevacizumab) 2 to 7 days before surgery has produced promising results. However, the so-called \u00abcrisis effect,\u00bb in which multiple fibrovascular elements rapidly dissolve in response to treatment with anti-angiogenic agents, may lead to worsening of retinal detachment. Anti-angiogenic agents may also lead to the development of denser fibrotic adhesions between the retina and the multiple fibrovascular elements, making tissue separation more difficult. Similar effects are seen with the anti-angiogenic agents LUCENTIS (ranibizumab) and EYLEA (aflibercept).<\/p>\n

In our practice, we generally avoid the use of these agents prior to surgery, as some patients may subsequently cancel surgery due to unwillingness to have their injections, exacerbating their systemic disease or delaying their release from the doctor. MACUGEN (pegaptanib) is a first-generation anti-angiogenic agent with lower specific binding of angiogenic agents. So far, our experience using this drug prior to surgery of patients with productive diabetic retinopathy has been more positive thanthose with higher affinity anti-VEGF agents. MACUGEN achieves regression of neovascularization and reduces the risk of intraoperative bleeding.<\/p>\n

Intravitreal steroid injection<\/strong><\/p>\n

In our hands, preoperative administration of the intravitreal implant dexamethasone 0.7 mg (Ozurdex, Allergan) facilitated the reestablishment and consolidation of neovascularization in patients with a high risk of productive diabetic retinopathy and extensive presence of multiple fibrovascular elements, without the rupture phenomenon or increased adhesion of multiple fibrovascular elements to the retina observed after anti-VEGF therapy. We insert the implant at the base of the vitreous, away from any cut point, and leave it embedded in the vitreous during vitrectomy so that it is not moved by intraoperative currents within the vitreous cavity.<\/p>\n

Because this implant inhibits multiple inflammatory cytokines and releases the active drug over 3 to 5 months, it allows us flexible scheduling. In our experience, the effectiveness of the implant is not diminished by using silicone oil after surgery and we have not seen complications with concomitant use with silicone oil.<\/p>\n

Tools<\/strong><\/p>\n

Cannulas with valve<\/strong><\/p>\n

During vitrectomy, the use of valve cannulas supports stable intraoperative fluidization and enhances the surgeon's control of intraocular pressure (IOP). The ability to increase intraocular pressure during vitrectomy allows the surgeon to control hemostasis, often without the need for diathermy. It is also recommended to use an adjustable infusion to control intraocular pressure during surgery.<\/p>\n

Intraoperative OCT<\/strong><\/p>\n

Intraoperative OCT provides the surgeon with anatomical imaging that can help guide and enhance decision-making during surgery. We identified that intraoperative OCT is useful in specific complex cases of productive diabetic retinopathy to identify tissue anatomy levels, visualize retinal structures beneath multiple fibrovascular elements, and diagnose incidental macular hole formation.<\/p>\n

Techniques<\/strong><\/p>\n

Cutting<\/strong><\/p>\n

Some surgeons have advocated different pushing techniques for surgery of productive diabetic retinopathy. We prefer to use traditional single- or double-handed cutting techniques for segmentation and detachment to avoid retinal tears associated with pushing techniques. Omnidirectional cutting techniques using different combinations of tools (e.g., vertical and curved scissors, vitreoretinal scissors and forceps) are particularly effective in strongly adherent multifibrovascular membranes and can be quite efficient if chosen correctly. Amphibial techniques require the use of broad-spectrum illumination systems or endoluminescent instruments.<\/p>\n

Hyalonectomy - Vitrectomy with instruments of different diameters<\/strong><\/p>\n

In recent years, small-gauge (25 and 27 gauge) vitrectomy equipment has improved so much that it is now the preferred equipment for the surgery of productive diabetic retinopathy. Small-diameter (e.g., 25\/27-gauge) vitreoretractors are advantageous for their ability to penetrate narrow incision planes often encountered in surgery for productive diabetic retinopathy. Compared with 23G and 25G instruments, 27G instruments lack the rigidity required to treat peripheral pathology. However, when passed through a 23G diameter trocar, a 27G vitreoretinal device may have more access to the periphery due to the increased freedom of rotation within the larger diameter trocar.<\/p>\n

We have adopted a mixed 27G, 25G and 23G platform for many of the cases of diabetic patients with retinal detachment. This combination allows us to take advantage of the benefits of the 27G vitreoretome when separating posterior and peripheral multiple fibrovascular elements and still have access to the full range of ancillary instruments available in 23G and 25G.<\/p>\n

CONCLUSIONS<\/strong><\/p>\n

Despite medical advances in the management of patients with diabetes, surgery remains essential for restoring vision in selected patients with vitreoretinal haemorrhage with blurring and ulcerative complications of productive diabetic retinopathy. Knowing which of these patients we can operate on, how to prepare them for surgery, and how to manage their expectations after surgery will never be an accurate process and therefore requires careful monitoring. For patients we treat surgically, new tools and refined techniques, including preoperative medication, the use of OCT intraoperatively and vitrectomy using small-diameter instruments, enhance our ability to manage their disease.<\/p>\n

WITH A MOMMA<\/strong><\/p>\n

    \n
  1. Surgery may be indicated for complications of productive diabetic retinopathy that include vitreous hemorrhage with opacity and retinal detachment.<\/li>\n
  2. Preoperative administration of a dexamethasone implant may help to achieve inhibition of neovascularization and trapping of multiple fibrovascular elements.<\/li>\n
  3. Surgeons can take advantage of the technical advantages of using different cutting tools and accessory instruments by performing mixed-diameter vitrectomy for complex diabetic traction surgery.<\/li>\n<\/ol>","protected":false},"excerpt":{"rendered":"

    \u0394\u03b9\u03b1\u03b2\u03b7\u03c4\u03b9\u03ba\u03ae \u03b1\u03bc\u03c6\u03b9\u03b2\u03bb\u03b7\u03c3\u03c4\u03c1\u03bf\u03b5\u03b9\u03b4\u03bf\u03c0\u03ac\u03b8\u03b5\u03b9\u03b1 \u0397 \u03b4\u03b9\u03b1\u03b2\u03b7\u03c4\u03b9\u03ba\u03ae \u03b1\u03bc\u03c6\u03b9\u03b2\u03bb\u03b7\u03c3\u03c4\u03c1\u03bf\u03b5\u03b9\u03b4\u03bf\u03c0\u03ac\u03b8\u03b5\u03b9\u03b1 (diabetic retinopathy) \u03b5\u03af\u03bd\u03b1\u03b9 \u03b7 \u03c0\u03b9\u03bf \u03c3\u03bf\u03b2\u03b1\u03c1\u03ae \u03b1\u03c0\u03cc \u03c4\u03b9\u03c2 \u03b4\u03b9\u03b1\u03b2\u03b7\u03c4\u03b9\u03ba\u03ad\u03c2 \u03bf\u03c6\u03b8\u03b1\u03bb\u03bc\u03b9\u03ba\u03ad\u03c2 \u03c0\u03b1\u03b8\u03ae\u03c3\u03b5\u03b9\u03c2. \u03a0\u03c1\u03bf\u03ba\u03b1\u03bb\u03b5\u03af \u03c3\u03bf\u03b2\u03b1\u03c1\u03ad\u03c2 \u03b2\u03bb\u03ac\u03b2\u03b5\u03c2 \u03c3\u03c4\u03b1 \u03b1\u03b9\u03bc\u03bf\u03c6\u03cc\u03c1\u03b1 \u03b1\u03b3\u03b3\u03b5\u03af\u03b1 \u03c0\u03bf\u03c5 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