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Long-term Diabetic Vitrectomy Results
Long-term Diabetic Vitrectomy Results Report of 10 Year Follow-up GEORGE
w.
BLANKENSHIP, MD, ROBERT MACHEMER, MD
Abstract: Ten year follow-up examinations were obtained on 72 cases having pars plana vitrectomies for diabetic retinopathy complications from 1970 to 1973. Forty-two percent of the cases maintained 6/60 or better visual acuities through the tenth year. The visual results were quite stable, with 53% of the cases having the same or better visual acuities at ten years compared with six months. Neovascular glaucoma developed in 11 eyes, usually during the first six months, and open-angle glaucoma developed in 16 eyes, usually after the five-year follow-up examination. Both types of glaucoma occurred almost exclusively in aphakic eyes. Cataracts developed in 75% of retained clear lenses. The vitreous cavities remained clear in 67% of the eyes, and the maculas were attached in 65% of the eyes 10 years following vitrectomy. Fundus neovascularization did not recur. [Key words: cataract, diabetic retinopathy, diabetic traction retinal detachments, diabetic vitreous hemorrhage, iris rubeosis, neovascular glaucoma, open-angle glaucoma, pars plana vitrectomy.] Ophthalmology 92:503-506, 1985
Pars plana vitrectomy has become the standard treatment for serious visual loss caused by dense nonclearing vitreous hemorrhage or traction retinal detachment involving the macula secondary to proliferative diabetic retinopathy. The initial six-month evaluations of diabetic vitrectomy results documented good visual recovery with many cases. I ,2 Five-year follow-up studies have found the initial beneficial visual and anatomical results to remain reasonably stable. 3,4 This report describes the visual and anatomical findings of diabetic vitrectomy cases after ten years of follow-
From the Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami School of Medicine, Miami, Florida, and Department of Ophthalmology, Duke University Eye Center, Duke University School of Medicine, Durham, North Carolina. Presented at the Eighty-ninth Annual Meeting of the American Academy of Ophthalmology, Atlanta, Georgia, November 11-15, 1984. Supported in part by The Bascom Palmer Eye Institute patients and contributors, Research to Prevent Blindness, Inc., New York, Florida Lions Eye Bank, and The Brenn Green Diabetic Retinopathy Funds, Miami. Reprint requests to George W. Blankenship, MD, Bascom Palmer Eye Institute, P.O. Box 016880, Miami, FL 33101.
up, and compares these long-term findings with the sixmonth and five-year results.
MATERIALS AND METHODS Between May 1970 and December 1973, the full-time faculty of the Bascom Palmer Eye Institute performed 202 pars plana vitrectomies for complications of diabetic retinopathy. Of these, 72 (35%) patients were available for ten-year follow-up examinations-l02 (50%) patients had died, 14 (8%) eyes had been enucleated, and the remaining 14 (7%) cases were lost to follow-up. All of the 72 cases involved in this series had followup examinations in excess of ten years following vitrectomy(average, 10 years, 9 months; range, 10-13 years). Information regarding the patients' general characteristics, past ophthalmic and medical histories, best corrected visual functions, and ophthalmic findings with slit lamp microscopy, gonioscopy, fundus contact lenses, and indirect ophthalmoscopy was recorded at the preoperative, six months, five years, and ten years postoperative examinations. Data regarding the operative procedures, complications, and findings were also recorded. All of the information was computerized. Occasionally, the follow-up data were incomplete due 503
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Table 1. Diabetic Vitrectomy Visual Acuities (72 cases) Visual Acutiy
VOLUME 92
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NUMBER 4
Table 3. Five-year Diabetic Vitrectomy Results (72 cases)
Preoperative
6-month
5-year
10-year
3% 7% 23% 67%
7% 49% 18% 21% 5%
13% 37% 13% 11% 26%
14% 28% 11% 17% 30%
6/6-6/12 6/15-6/60 6/90-1/60 HM-LP NLP
•
HM = hand motions; LP = light perception; NLP = no light perception.
to inadequacies of the examinations performed elsewhere, or more often, because opacities of the optical media made visualization of the posterior structures impossible. The visual acuities were grouped into broad categories: (1) reading vision, 6/6 to 6/12 (20/15-20/40); (2) decreased visual acuity but not legal blindness, 6/15 to 6/ 60 (20/50-20/200); (3) ambulating vision, 6/90 to 1/60 (20/300-finger counting); (4) minimal vision function (hand movements-light perception); and (5) no light perception.
Preoperative Visual Acuity HM-LP 6/90-1/60 6/15-6/60 6/6-6/12
Five-year Visual Acuity 6/6-12
6/15-60
7
14
1
6/90-1/60
HM-LP
NLP
4 ___ 7
9 ___ 4
16
1
___ 4
2
1
1
HM = hand motions; LP = light perception; NLP = no light perception. Numbers above the diagonal line are the number of eyes with improved vision, those along the diagonal line have the same vision, and those below are the number of eyes with poorer vision.
As the presented cases were operated in the early developmental period of vitreous surgery the most frequent indication for pars plana vitrectomy for diabetic complications was dense nonclearing vitreous hemorrhage which involved 52 (72%) of these 72 cases, with 16 (22%) having traction detachment involving the macula, and the remaining 4 (6%) cases having both opaque vitreous hemorrhage and macular detachment. Most cases did not require any additional surgery following vitrectomy, but occasionally additional operations were performed. Within six months of the vitrectomy, eight (11 %) eyes had scleral buckles, four (5%) had glaucoma operations, and one (1 %) had received photocoagulation. By five years, an additional three (4%) eyes had scleral buckling procedures, one (I %) had glaucoma surgery, three (4%) had cataract extractions, three (4%) had vitreous cavity washouts for recurrent vitreous hemorrhages, and one (1 %) had photocoagulation. Two (3%) additional eyes had cataract surgery between the five- and ten-year follow-up examinations.
Table 1 shows the levels of visual acuity for each case at the preoperative, six-months, five-year, and ten-year follow-up examinations. Preoperatively, most of the cases had vision reduced to the hand movement or light perception range. The majority of cases had 6/60 or better best corrected visual acuities at the six-month and five-year follow-up examinations, and 42% continued to have visual acuities at this level at the ten-year followup examination. The visual results of the 72 eyes comparing the preoperative and postoperative visual acuities are shown in Table 2 for six months, Table 3 for five years, and in Table 4 for ten years. The visual acuities for the individual cases were quite stable as shown in Table 5, which compares the visual acuities of each case at 6 months and at 10 years, and in Table 6, which compares the five-year and ten-year follow-up visual acuities for each case. Nine (13%) of the 72 cases had better visual acuities at the ten-year examination than at six months, 29 (40%) had the same visual acuities, but 38 (47%) had poorer vision at the ten-year examination (Table 5). Between the three- and ten-year examinations, 5 (7%) cases had improved visual acuities, 52 (72%) had the same visions, but 15 (21 %) had deteriorated (Table 6). Most of the cases with poor visual acuities in the hand movements and light perception range six months following surgery continued to deteriorate, becoming phthisical with no light perception at the later examinations. Four (5%) of the cases with 6/15 to 6/60 visual acuities at the six-month examination had some residual vitreous cavity haze which gradually
Table 2. Six-month Diabetic Vitrectomy Visual Results (72 cases)
Table 4. Ten-year Diabetic Vitrectomy Visual Results (72 cases)
RESULTS
Preoperative Visual Acuity HM-LP 6/90-1/60 6/15-6/60 6/6-6/12
Six-month Visual Acuity 6/6-12
6/15-60
6/90-1/60
HM-LP
7 ___ 14 2 21 1 10 ___ 5 1 1 __ 3 1
NLP
4
1
HM = hand motions; LP = light perception; NLP = no light perception Numbers above the diagonal line are the number of eyes with improved vision, those along the diagonal line have the same vision, and those below are the number of eyes with poorer vision.
504
Preoperative Visual Acuity HM-LP 6/90-1/60 6/15-6/60 6/6-6/12
Ten-year Visual Acuity 6/6-12
6/15-60
6 1
12
6/90-1/60
HM-LP
3 ______ 8 7 ____ 3 4
2 ____ 1
1
1
1
NLP 19
2
1
HM = hand motions; LP = light perception, NLP = no light perception. Numbers above the diagonal line are the number of eyes with improved vision, those along the diagonal line have the same viSion, and those below are the number of eyes with poorer vision.
BLANKENSHIP AND MACHEMER
Table 5. Diabetic Vitrectomy Visual Acuity Stabiity (72 cases) Six-month Visual Acutiy NLP HM-LP 6/90-1/60 6/15-6/60 6/6-6/12
Ten-year Visual Acuity 6/6-12
2
6/15-60
6/90-1/60
HM-LP
3~ 8
4 ____ 16 4 1
NLP
4 5 ----10 3 5
4
Table 6. Diabetic Vitrectomy Visual Acuity Stability (72 cases) Ten-year Visual Acuity 6/6-12
6/15-60
6/90-1/60
None Pupil Angle Obscured
Six-month
Five-year
Ten-year
68% 4% 27% 1%
65%
68%
17% 15%
1% 28%
3%
3%
3
cleared and resulted in further visual improvement at the subsequent examinations. Iris rubeosis was a frequent postvitrectomy complication since lens removal was usually performed in conjunction with the vitrectomy. The incidence of iris rubeosis and is geographical distribution are shown in Table 7 at the various postoperative examinations. Iris rubeosis developed during the first six months following vitrectomy, and later development was rare. Eyes with extensive angle rubeosis gradually underwent further deterioration with phthisis and corneal opacification usually occurring after the two- and five-year follow-up examination, making it impossible to visualize the irises at the later examinations. Most of the cases (64%) never developed glaucoma during the ten-year follow-up period, but when glaucoma developed, there was a strong tendency towards neovascular glaucoma during the first six months following vitrectomy and open-angle glaucoma during the later period (Table 8). Aphakic eyes were affected much more than phakic eyes. In the 52 aphakic eyes, 10 developed neovascular glaucoma and 15 developed open-angle glaucoma. There was only one case of each type of glaucoma in the 20 phakic eyes. At the five-year examination all of the neovascular glaucoma cases were blind and phthisical, but the open-angle glaucoma cases were usually medically controlled. Removal of the lens was a frequent component of the vitrectomy operations because of coexistent lens
NLP HM-LP 6/90-1/60 6/15-6/60 6/6-6/12
DIABETIC VITRECTOMY
Table 7. Diabetic Vitrectomy Iris Rubeosis (72 cases)
HM = hand motions; LP = light perception; NLP = no light perception. Numbers above the diagonal line are the number of eyes with improved vision, those along the diagonal line have the same vision, and those below are the number of eyes with poorer vision.
Five-year Visual Acuity
•
opacities and the increased efficiency with which recurrent vitreous cavity blood would spontaneously clear from the aphakic eyes. There was a gradual tendency for cataract development, as shown in Table 9, with only 5 of the 20 lenses remaining clear at the ten-year follow-up examination. The younger patients tended to have gradual increasing posterior subcapsular opacities, but the older patients had increasing nuclear sclerosis. Several cases hd cataract surgery with good visual results, but dense cataracts were often coexistent with other more seqous ophthalmic problems, and cataract surgery was not indicated. The main indication for vitrectomy in this series was dense, nonclearing vitreous hemorrhage, and the postvitrectomy vitreous cavities remained clear in the majority of cases, as shown in Table 10. Of the 58 eyes that had clear vitreous cavities at the six-month followup examination, 48 (83%) continued to be clear at the ten-year follow-up examination, 2 (3%) were opaque, and the remaining 8 (14%) had anterior segment opacities which obscured the vitreous cavity. Many of the cases had macular detachments before vitrectomy; the majority of cases had completely attached retinas during the follow-up period as shown in Table 11. Of the 45 eyes that had completely attached retinas at the six-month postoperative examination, 40 (89%) continued to have completely attached retinas at the ten-year follow-up examination, with the remaining 5 (11 %) being obscured by anterior segment and vitreous opacities. None of the 72 cases were observed to have any recurrent retinal or disc neovascular proliferation.
DISCUSSION We are aware that this series is somewhat selective in that 14 enucleated eyes and 14 eyes which were lost to follow-up have been excluded. Our interest, however, is Table 8. Diabetic Vitrectomy Glaucoma (72 cases)
HM-LP
NLP
_ _ 19
7 2 3--- 2 3 3 16 - - - - 5 7 --- 2
1 2
HM = hand motions; LP = light perception; NLP = no light perception. Numbers above the diagonal line are the number of eyes with improved vision, those along the diagonal line have the same vision, and those below are the number of eyes with poorer vision.
No. Cases with Glaucoma Time Onset following vitrectomy 0-6 months 6 months-2 years 5-10 years 10-year Lens Status Phakic Aphakic
Neovascular
9
2
1 10
Open-angle 4 4
8
1 15
505
OPHTHALMOLOGY
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Table 9. Diabetic Postvitrectomy Cataract Five-year
Ten-year
15 4
8
5
8 3
5
1 9
1
1
directed at those eyes that could be examined over a ten-year period. The vitrectomy procedures in this series were performed at the start of closed pars plana vitreous surgery? during a period of rapidly changing vitrectomy instrumentation and evolving techniques. 5,6 Most of the procedures were performed without intraocular fiberoptics, pars plana cannulas, transvitreal diathermy, or bimanual techniques, and many technical problems that no longer exist had to be solved. Miniaturized equipment such as vitreous scissors, bipolar transvitreal diathermy, air pumps, and fiberoptics for laser treatment did not exist. Various aspects of the cases in this series have previously been reported. 1,3,5,7,8 This series is very similar to the initially successful cases reported by Rice and Miche1s. 4 Most of the complications following vitrectomy, such as retinal detachments, neovascular glaucoma, and recurrent vitreous cavity bleeding occurred within the first few months of vitrectomy. The scleral buckles and vitreous cavity washout procedures performed after the six-month examinations were for detachments and hemorrhages that had occurred earlier but either had not been detected until the six-month examination, or treatment was deferred for convenience of the patients until their scheduled six-month examination. Surprisingly good initial visual results were obtained considering the equipment and techniques. Although the visual results tended to be surprisingly stable, there was not as much stability in the second five years as in the first five years. 3 ,4 Improvements in vision following the six-month examinations were usually due to gradual clearing of residual vitreous cavity hemorrhages, and after five years from cataract extractions in two cases, and the reason for improvement was not apparent in the remaining three cases. Dramatic loss of vision between follow-up examinations was unusual and often related to continued deterioration of eyes in which surgery was not initially successful. A specific cause for more subtle loss of vision was usually not apparent, but probably related to macular and disc atrophy from vascular occlusive problems. The anatomical results were also very stable, with the exception of anterior segment opacification between the Table 10. Diabetic Vitrectomy Vitreous Cavity Clarity (72 cases)
Clear Opaque Obscured
506
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Table 11. Diabetic Vitrectomy Retinal Status (72 cases)
Six-month Clear Moderate Dense Aphakic
•
Preoperative
Six-month
Five-year
Ten-year
22% 78%
81% 7% 12%
71% 1% 28%
67% 3% 30%
Attached Perimacular detachment Macular detachment Total detachment Obscured
Preoperative
Six-month
Five-year
Ten-year
47%
63%
64%
64%
25%
8%
6%
1%
18%
4%
10%
7% 18%
1% 1% 29%
1% 33%
two- and five-year follow-up examinations in the cases of neovascular glaucoma. The development of neovascular glaucoma in the early postvitrectomy period and its association. with aphakia and retinal detachments has been preVIously reported. 8 ,9 The large and increasing incidence of openangle glaucoma during the later postvitrectomy perio? stresses the importance of continued follow-up examInations. There is also a strong association of glaucoma with aphakia; glaucoma obviously occurs much more frequently in these eyes than in aphakic eyes that have not had vitrectomies. 1O Neovascular proliferation did not redevelop in any of the eyes during the ten years following vitrectomy. In summary, diabetic eyes which have undergone successful vitrectomy will usually maintain good vision over many years after the initial postoperative recovery. Long-term follow-up is needed to detect and control open-angle aphakic glaucoma.
REFERENCES 1. Mandelcorn MS, Blankenship G, Machemer R. Pars plana vitrectorny for the management of severe diabetic retinopathy. Am J Ophthalmol 1976; 81:561-70. 2. Aaberg TM. Results of 100 consecutive vitrectomy procedures. In: McPherson A, ed. New and Controversial Aspects of Vitreoretinal Surgery. St Louis: CV Mosby, 1977; 245-9. 3. Blankenship GW. Stability of pars plana vitrectomy results for diabetic retinopathy complications; a comparison of five· year and six-month postvitrectomy findings. Arch Ophthalmol1981; 99:100912. 4. Rice TA, Michels RG. Long-term anatomic and functional results of vitrectomy for diabetic retinopathy. Arn J Ophthalmol1980; 90:297303. 5. Machemer R. A new concept for vitreous surgery. 2. Surgical technique and complications. Am J Ophthalrnol 1972; 74:1022-33. 6. Parel JM, Machemer R, Aumayr W. A new concept for vitreous surgery. 4. Irnprovernents in instrurnentation and illumination. Am J Ophthalmol 1974; 77:6-12. 7. Faulborn J, Conway BP, Machemer R. Surgical complications of pars plana vitreous surgery. Ophthalmology 1978; 85:116-25. 8. Blankenship GW. The lens influence on diabetic vitrectomy results; report of a prospective randomized study. Arch Ophthalmol 1980; 98:2196-8. 9. Rice TA, Michels RG, Maguire MG, Rice EF. The effect of lensectorny on the incidence of iris neovascularization and neovascular glaucoma after vitrectomy for diabetic retinopathy. Am J Ophthalmol 1983; 95:1-11. 10. Kessing SV, Rasmussen KE. Aphakic glaucoma. Acta Ophthalmol 1977; 55:717-25.
w.
BLANKENSHIP, MD, ROBERT MACHEMER, MD
Abstract: Ten year follow-up examinations were obtained on 72 cases having pars plana vitrectomies for diabetic retinopathy complications from 1970 to 1973. Forty-two percent of the cases maintained 6/60 or better visual acuities through the tenth year. The visual results were quite stable, with 53% of the cases having the same or better visual acuities at ten years compared with six months. Neovascular glaucoma developed in 11 eyes, usually during the first six months, and open-angle glaucoma developed in 16 eyes, usually after the five-year follow-up examination. Both types of glaucoma occurred almost exclusively in aphakic eyes. Cataracts developed in 75% of retained clear lenses. The vitreous cavities remained clear in 67% of the eyes, and the maculas were attached in 65% of the eyes 10 years following vitrectomy. Fundus neovascularization did not recur. [Key words: cataract, diabetic retinopathy, diabetic traction retinal detachments, diabetic vitreous hemorrhage, iris rubeosis, neovascular glaucoma, open-angle glaucoma, pars plana vitrectomy.] Ophthalmology 92:503-506, 1985
Pars plana vitrectomy has become the standard treatment for serious visual loss caused by dense nonclearing vitreous hemorrhage or traction retinal detachment involving the macula secondary to proliferative diabetic retinopathy. The initial six-month evaluations of diabetic vitrectomy results documented good visual recovery with many cases. I ,2 Five-year follow-up studies have found the initial beneficial visual and anatomical results to remain reasonably stable. 3,4 This report describes the visual and anatomical findings of diabetic vitrectomy cases after ten years of follow-
From the Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami School of Medicine, Miami, Florida, and Department of Ophthalmology, Duke University Eye Center, Duke University School of Medicine, Durham, North Carolina. Presented at the Eighty-ninth Annual Meeting of the American Academy of Ophthalmology, Atlanta, Georgia, November 11-15, 1984. Supported in part by The Bascom Palmer Eye Institute patients and contributors, Research to Prevent Blindness, Inc., New York, Florida Lions Eye Bank, and The Brenn Green Diabetic Retinopathy Funds, Miami. Reprint requests to George W. Blankenship, MD, Bascom Palmer Eye Institute, P.O. Box 016880, Miami, FL 33101.
up, and compares these long-term findings with the sixmonth and five-year results.
MATERIALS AND METHODS Between May 1970 and December 1973, the full-time faculty of the Bascom Palmer Eye Institute performed 202 pars plana vitrectomies for complications of diabetic retinopathy. Of these, 72 (35%) patients were available for ten-year follow-up examinations-l02 (50%) patients had died, 14 (8%) eyes had been enucleated, and the remaining 14 (7%) cases were lost to follow-up. All of the 72 cases involved in this series had followup examinations in excess of ten years following vitrectomy(average, 10 years, 9 months; range, 10-13 years). Information regarding the patients' general characteristics, past ophthalmic and medical histories, best corrected visual functions, and ophthalmic findings with slit lamp microscopy, gonioscopy, fundus contact lenses, and indirect ophthalmoscopy was recorded at the preoperative, six months, five years, and ten years postoperative examinations. Data regarding the operative procedures, complications, and findings were also recorded. All of the information was computerized. Occasionally, the follow-up data were incomplete due 503
OPHTHALMOLOGY
•
APRIL 1985
Table 1. Diabetic Vitrectomy Visual Acuities (72 cases) Visual Acutiy
VOLUME 92
•
NUMBER 4
Table 3. Five-year Diabetic Vitrectomy Results (72 cases)
Preoperative
6-month
5-year
10-year
3% 7% 23% 67%
7% 49% 18% 21% 5%
13% 37% 13% 11% 26%
14% 28% 11% 17% 30%
6/6-6/12 6/15-6/60 6/90-1/60 HM-LP NLP
•
HM = hand motions; LP = light perception; NLP = no light perception.
to inadequacies of the examinations performed elsewhere, or more often, because opacities of the optical media made visualization of the posterior structures impossible. The visual acuities were grouped into broad categories: (1) reading vision, 6/6 to 6/12 (20/15-20/40); (2) decreased visual acuity but not legal blindness, 6/15 to 6/ 60 (20/50-20/200); (3) ambulating vision, 6/90 to 1/60 (20/300-finger counting); (4) minimal vision function (hand movements-light perception); and (5) no light perception.
Preoperative Visual Acuity HM-LP 6/90-1/60 6/15-6/60 6/6-6/12
Five-year Visual Acuity 6/6-12
6/15-60
7
14
1
6/90-1/60
HM-LP
NLP
4 ___ 7
9 ___ 4
16
1
___ 4
2
1
1
HM = hand motions; LP = light perception; NLP = no light perception. Numbers above the diagonal line are the number of eyes with improved vision, those along the diagonal line have the same vision, and those below are the number of eyes with poorer vision.
As the presented cases were operated in the early developmental period of vitreous surgery the most frequent indication for pars plana vitrectomy for diabetic complications was dense nonclearing vitreous hemorrhage which involved 52 (72%) of these 72 cases, with 16 (22%) having traction detachment involving the macula, and the remaining 4 (6%) cases having both opaque vitreous hemorrhage and macular detachment. Most cases did not require any additional surgery following vitrectomy, but occasionally additional operations were performed. Within six months of the vitrectomy, eight (11 %) eyes had scleral buckles, four (5%) had glaucoma operations, and one (1 %) had received photocoagulation. By five years, an additional three (4%) eyes had scleral buckling procedures, one (I %) had glaucoma surgery, three (4%) had cataract extractions, three (4%) had vitreous cavity washouts for recurrent vitreous hemorrhages, and one (1 %) had photocoagulation. Two (3%) additional eyes had cataract surgery between the five- and ten-year follow-up examinations.
Table 1 shows the levels of visual acuity for each case at the preoperative, six-months, five-year, and ten-year follow-up examinations. Preoperatively, most of the cases had vision reduced to the hand movement or light perception range. The majority of cases had 6/60 or better best corrected visual acuities at the six-month and five-year follow-up examinations, and 42% continued to have visual acuities at this level at the ten-year followup examination. The visual results of the 72 eyes comparing the preoperative and postoperative visual acuities are shown in Table 2 for six months, Table 3 for five years, and in Table 4 for ten years. The visual acuities for the individual cases were quite stable as shown in Table 5, which compares the visual acuities of each case at 6 months and at 10 years, and in Table 6, which compares the five-year and ten-year follow-up visual acuities for each case. Nine (13%) of the 72 cases had better visual acuities at the ten-year examination than at six months, 29 (40%) had the same visual acuities, but 38 (47%) had poorer vision at the ten-year examination (Table 5). Between the three- and ten-year examinations, 5 (7%) cases had improved visual acuities, 52 (72%) had the same visions, but 15 (21 %) had deteriorated (Table 6). Most of the cases with poor visual acuities in the hand movements and light perception range six months following surgery continued to deteriorate, becoming phthisical with no light perception at the later examinations. Four (5%) of the cases with 6/15 to 6/60 visual acuities at the six-month examination had some residual vitreous cavity haze which gradually
Table 2. Six-month Diabetic Vitrectomy Visual Results (72 cases)
Table 4. Ten-year Diabetic Vitrectomy Visual Results (72 cases)
RESULTS
Preoperative Visual Acuity HM-LP 6/90-1/60 6/15-6/60 6/6-6/12
Six-month Visual Acuity 6/6-12
6/15-60
6/90-1/60
HM-LP
7 ___ 14 2 21 1 10 ___ 5 1 1 __ 3 1
NLP
4
1
HM = hand motions; LP = light perception; NLP = no light perception Numbers above the diagonal line are the number of eyes with improved vision, those along the diagonal line have the same vision, and those below are the number of eyes with poorer vision.
504
Preoperative Visual Acuity HM-LP 6/90-1/60 6/15-6/60 6/6-6/12
Ten-year Visual Acuity 6/6-12
6/15-60
6 1
12
6/90-1/60
HM-LP
3 ______ 8 7 ____ 3 4
2 ____ 1
1
1
1
NLP 19
2
1
HM = hand motions; LP = light perception, NLP = no light perception. Numbers above the diagonal line are the number of eyes with improved vision, those along the diagonal line have the same viSion, and those below are the number of eyes with poorer vision.
BLANKENSHIP AND MACHEMER
Table 5. Diabetic Vitrectomy Visual Acuity Stabiity (72 cases) Six-month Visual Acutiy NLP HM-LP 6/90-1/60 6/15-6/60 6/6-6/12
Ten-year Visual Acuity 6/6-12
2
6/15-60
6/90-1/60
HM-LP
3~ 8
4 ____ 16 4 1
NLP
4 5 ----10 3 5
4
Table 6. Diabetic Vitrectomy Visual Acuity Stability (72 cases) Ten-year Visual Acuity 6/6-12
6/15-60
6/90-1/60
None Pupil Angle Obscured
Six-month
Five-year
Ten-year
68% 4% 27% 1%
65%
68%
17% 15%
1% 28%
3%
3%
3
cleared and resulted in further visual improvement at the subsequent examinations. Iris rubeosis was a frequent postvitrectomy complication since lens removal was usually performed in conjunction with the vitrectomy. The incidence of iris rubeosis and is geographical distribution are shown in Table 7 at the various postoperative examinations. Iris rubeosis developed during the first six months following vitrectomy, and later development was rare. Eyes with extensive angle rubeosis gradually underwent further deterioration with phthisis and corneal opacification usually occurring after the two- and five-year follow-up examination, making it impossible to visualize the irises at the later examinations. Most of the cases (64%) never developed glaucoma during the ten-year follow-up period, but when glaucoma developed, there was a strong tendency towards neovascular glaucoma during the first six months following vitrectomy and open-angle glaucoma during the later period (Table 8). Aphakic eyes were affected much more than phakic eyes. In the 52 aphakic eyes, 10 developed neovascular glaucoma and 15 developed open-angle glaucoma. There was only one case of each type of glaucoma in the 20 phakic eyes. At the five-year examination all of the neovascular glaucoma cases were blind and phthisical, but the open-angle glaucoma cases were usually medically controlled. Removal of the lens was a frequent component of the vitrectomy operations because of coexistent lens
NLP HM-LP 6/90-1/60 6/15-6/60 6/6-6/12
DIABETIC VITRECTOMY
Table 7. Diabetic Vitrectomy Iris Rubeosis (72 cases)
HM = hand motions; LP = light perception; NLP = no light perception. Numbers above the diagonal line are the number of eyes with improved vision, those along the diagonal line have the same vision, and those below are the number of eyes with poorer vision.
Five-year Visual Acuity
•
opacities and the increased efficiency with which recurrent vitreous cavity blood would spontaneously clear from the aphakic eyes. There was a gradual tendency for cataract development, as shown in Table 9, with only 5 of the 20 lenses remaining clear at the ten-year follow-up examination. The younger patients tended to have gradual increasing posterior subcapsular opacities, but the older patients had increasing nuclear sclerosis. Several cases hd cataract surgery with good visual results, but dense cataracts were often coexistent with other more seqous ophthalmic problems, and cataract surgery was not indicated. The main indication for vitrectomy in this series was dense, nonclearing vitreous hemorrhage, and the postvitrectomy vitreous cavities remained clear in the majority of cases, as shown in Table 10. Of the 58 eyes that had clear vitreous cavities at the six-month followup examination, 48 (83%) continued to be clear at the ten-year follow-up examination, 2 (3%) were opaque, and the remaining 8 (14%) had anterior segment opacities which obscured the vitreous cavity. Many of the cases had macular detachments before vitrectomy; the majority of cases had completely attached retinas during the follow-up period as shown in Table 11. Of the 45 eyes that had completely attached retinas at the six-month postoperative examination, 40 (89%) continued to have completely attached retinas at the ten-year follow-up examination, with the remaining 5 (11 %) being obscured by anterior segment and vitreous opacities. None of the 72 cases were observed to have any recurrent retinal or disc neovascular proliferation.
DISCUSSION We are aware that this series is somewhat selective in that 14 enucleated eyes and 14 eyes which were lost to follow-up have been excluded. Our interest, however, is Table 8. Diabetic Vitrectomy Glaucoma (72 cases)
HM-LP
NLP
_ _ 19
7 2 3--- 2 3 3 16 - - - - 5 7 --- 2
1 2
HM = hand motions; LP = light perception; NLP = no light perception. Numbers above the diagonal line are the number of eyes with improved vision, those along the diagonal line have the same vision, and those below are the number of eyes with poorer vision.
No. Cases with Glaucoma Time Onset following vitrectomy 0-6 months 6 months-2 years 5-10 years 10-year Lens Status Phakic Aphakic
Neovascular
9
2
1 10
Open-angle 4 4
8
1 15
505
OPHTHALMOLOGY
•
APRIL 1985
Table 9. Diabetic Postvitrectomy Cataract Five-year
Ten-year
15 4
8
5
8 3
5
1 9
1
1
directed at those eyes that could be examined over a ten-year period. The vitrectomy procedures in this series were performed at the start of closed pars plana vitreous surgery? during a period of rapidly changing vitrectomy instrumentation and evolving techniques. 5,6 Most of the procedures were performed without intraocular fiberoptics, pars plana cannulas, transvitreal diathermy, or bimanual techniques, and many technical problems that no longer exist had to be solved. Miniaturized equipment such as vitreous scissors, bipolar transvitreal diathermy, air pumps, and fiberoptics for laser treatment did not exist. Various aspects of the cases in this series have previously been reported. 1,3,5,7,8 This series is very similar to the initially successful cases reported by Rice and Miche1s. 4 Most of the complications following vitrectomy, such as retinal detachments, neovascular glaucoma, and recurrent vitreous cavity bleeding occurred within the first few months of vitrectomy. The scleral buckles and vitreous cavity washout procedures performed after the six-month examinations were for detachments and hemorrhages that had occurred earlier but either had not been detected until the six-month examination, or treatment was deferred for convenience of the patients until their scheduled six-month examination. Surprisingly good initial visual results were obtained considering the equipment and techniques. Although the visual results tended to be surprisingly stable, there was not as much stability in the second five years as in the first five years. 3 ,4 Improvements in vision following the six-month examinations were usually due to gradual clearing of residual vitreous cavity hemorrhages, and after five years from cataract extractions in two cases, and the reason for improvement was not apparent in the remaining three cases. Dramatic loss of vision between follow-up examinations was unusual and often related to continued deterioration of eyes in which surgery was not initially successful. A specific cause for more subtle loss of vision was usually not apparent, but probably related to macular and disc atrophy from vascular occlusive problems. The anatomical results were also very stable, with the exception of anterior segment opacification between the Table 10. Diabetic Vitrectomy Vitreous Cavity Clarity (72 cases)
Clear Opaque Obscured
506
VOLUME 92
•
NUMBER 4
Table 11. Diabetic Vitrectomy Retinal Status (72 cases)
Six-month Clear Moderate Dense Aphakic
•
Preoperative
Six-month
Five-year
Ten-year
22% 78%
81% 7% 12%
71% 1% 28%
67% 3% 30%
Attached Perimacular detachment Macular detachment Total detachment Obscured
Preoperative
Six-month
Five-year
Ten-year
47%
63%
64%
64%
25%
8%
6%
1%
18%
4%
10%
7% 18%
1% 1% 29%
1% 33%
two- and five-year follow-up examinations in the cases of neovascular glaucoma. The development of neovascular glaucoma in the early postvitrectomy period and its association. with aphakia and retinal detachments has been preVIously reported. 8 ,9 The large and increasing incidence of openangle glaucoma during the later postvitrectomy perio? stresses the importance of continued follow-up examInations. There is also a strong association of glaucoma with aphakia; glaucoma obviously occurs much more frequently in these eyes than in aphakic eyes that have not had vitrectomies. 1O Neovascular proliferation did not redevelop in any of the eyes during the ten years following vitrectomy. In summary, diabetic eyes which have undergone successful vitrectomy will usually maintain good vision over many years after the initial postoperative recovery. Long-term follow-up is needed to detect and control open-angle aphakic glaucoma.
REFERENCES 1. Mandelcorn MS, Blankenship G, Machemer R. Pars plana vitrectorny for the management of severe diabetic retinopathy. Am J Ophthalmol 1976; 81:561-70. 2. Aaberg TM. Results of 100 consecutive vitrectomy procedures. In: McPherson A, ed. New and Controversial Aspects of Vitreoretinal Surgery. St Louis: CV Mosby, 1977; 245-9. 3. Blankenship GW. Stability of pars plana vitrectomy results for diabetic retinopathy complications; a comparison of five· year and six-month postvitrectomy findings. Arch Ophthalmol1981; 99:100912. 4. Rice TA, Michels RG. Long-term anatomic and functional results of vitrectomy for diabetic retinopathy. Arn J Ophthalmol1980; 90:297303. 5. Machemer R. A new concept for vitreous surgery. 2. Surgical technique and complications. Am J Ophthalrnol 1972; 74:1022-33. 6. Parel JM, Machemer R, Aumayr W. A new concept for vitreous surgery. 4. Irnprovernents in instrurnentation and illumination. Am J Ophthalmol 1974; 77:6-12. 7. Faulborn J, Conway BP, Machemer R. Surgical complications of pars plana vitreous surgery. Ophthalmology 1978; 85:116-25. 8. Blankenship GW. The lens influence on diabetic vitrectomy results; report of a prospective randomized study. Arch Ophthalmol 1980; 98:2196-8. 9. Rice TA, Michels RG, Maguire MG, Rice EF. The effect of lensectorny on the incidence of iris neovascularization and neovascular glaucoma after vitrectomy for diabetic retinopathy. Am J Ophthalmol 1983; 95:1-11. 10. Kessing SV, Rasmussen KE. Aphakic glaucoma. Acta Ophthalmol 1977; 55:717-25.