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Vitrectomy for Diffuse Macular Edema in Cases of Diabetic Retinopathy
BRIEF REPORTS
Vitrectomy for Diffuse Macular Edema in Cases of Diabetic Retinopathy Naoko Tachi, M.D., and Nobuchika Ogino, M.D. PURPOSE: To ascertain the effects of posterior vitreous detachment for diffuse diabetic macular edema. METHODS: We performed vitrectomy on 58 eyes of 41 consecutive patients with diabetic macular edema without posterior vitreous detachment. Fol low-up was done at 12 months postoperatively. RESULTS: In 57 of 58 eyes after vitrectomy and posterior vitreous detachment, macular edema re solved, and diffuse fluorescein leakage disappeared in 35 of 36 eyes examined at the 12th month. Visual improvement was statistically significant (P < .0001, paired t test). CONCLUSION: In eyes with diffuse diabetic macular edema and without posterior vitreous de tachment, vitrectomy with posterior vitreous detachment may be effective.
I
N OUR EXPERIENCE, MANY EYES OF PATIENTS WITH
diabetic macular edema have demonstrated im provement after spontaneous posterior vitreous de tachment1 or vitrectomy for proliferative diabetic retinopathy. Lewis and associates2 reported vitrectomy for diabetic macular edema with a thickened and taut
Accepted for publication March 15, 1996. Department of Ophthalmology, Aichi Medical University. Inquiries to Naoko Tachi, M.D., Department of Ophthalmology, Shinseikai Toyama Hospital, 89-10 Shimowaka, Daimon-cho, Imizu, Toyama 939-02, Japan; fax: 81-766-52-2197; E-mail: [email protected]
258
vitreous membrane. The present prospective study was conducted to ascertain whether vitrectomy might be beneficial for treatment of diabetic macular edema associated with an attached premacular posterior hyaloid but without a thick vitreous membrane. We treated 58 eyes of 41 consecutive patients (21 men and 20 women) with type II diabetes mellitus and diabetic macular edema without posterior vitre ous detachment. The average age at the time of surgery was 57.5 years (range, 42 to 79 years). Eleven eyes had had grid photocoagulation and all had undergone panretinal photocoagulation. The crystal line lens was clear in 21 eyes, demonstrated mild nuclear sclerosis in 33 eyes, and showed pseudophakia in four eyes. Informed consent was obtained from each patient before surgery. We performed combined phacoemulsification and aspiration, intraocular lens implantation, and vitrectomy on 38 eyes of 28 pa tients because postoperative cataract surgery is inevi table in elderly patients,3 and the anterior vitreous cannot be removed in a phakic eye because anterior proliferation may result.4 Preoperatively, vitreous attachment over the macu lar region had been noted in all eyes under the biomicroscope, with no visible vitreous membrane on the surface of the macula. After core vitrectomy with the three-port system, posterior vitreous detachment was achieved by suction. The posterior hyaloid mem brane was then detectable with a Weiss ring, allowing resection with a vitreous cutter. The macular edema resolved in 27 (46.6%) of 58 eyes within three months, in 12 eyes (20.7%) widiin three to six months, and in 18 eyes (31.0%) from six to 12 months. Thirty-six eyes were followed up with fluorescein angiography. Preoperatively, a deep and diffuse pattern of leakage existed in the macula of the
AMERICAN JOURNAL OF OPHTHALMOLOGY
AUGUST 1996
Fig. 1 (Tachi and Ogino). Left, Preoperative fluorescein angiography of a 51-year-old woman whose visual acuity measurements are indicated in Figure 2 with an asterisk. There is diffuse fluorescein leakage and cystoid macular edema. Right, 12 months postoperatively. Both diffuse fluorescein leakage and cystoid macular edema are no longer remarkable.
20/20
20/200
2/200
POSTOPERATIVE VISUAL ACUITY
Fig. 2 (Tachi and Ogino). Visual outcome one year after vitrectomy. Best-corrected visual acuity was measured preoperatively and 12 months postoperatively. Closed circles indicates 19 eyes that underwent pars plana vitrectomy; open circles, 38 eyes that underwent com bined phacoemulsification and aspiration, intraocular lens implantation, and pars plana vitrectomy; triangle, a case in which combined surgery for the treatment of vitreous hemorrhage was performed four months after the first pars plana vitrectomy. The closed circle with an asterisk indicates an eye of which preoperative and postoperative fluorescein angiograms are shown in Fig ure 1.
VOL.122, N o . 2
36 eyes, which disappeared in 27 (75%) of 36 eyes by the sixth month and remained in only one (2.8%) of the eyes at the 12th month. The cystoid macular edema observed in 16 eyes preoperatively had disap peared in ten (62.5%) of 16 eyes at the sixth month and was observed in only three eyes (18.8%) at the 12th month (Fig. 1). At the 12th postoperative month, visual acuity had improved by more than one line in 31 (53.4%) of 58 eyes, worsened in nine eyes (15.5%) by more than one line, and had not changed in 18 eyes (31.0%) (Fig. 2). Mean logMAR, the logarithm of the mini mal angle of resolution,5 was significantly improved from the preoperative 1.029 to 0.751 at the 12th month (P < .0001, paired t test). Complications included intraoperative retinal tear formation in 12 (20.7%) of 58 eyes, vitreous hemorrhage in seven eyes (12.1%), cataract formation in six eyes (10.3%), development of an epiretinal membrane in six eyes (10.3%), and neovascular glaucomas in two eyes (3.4%), as well as rhegmatogenous retinal detach ment and another secondary glaucoma, each occur ring in one eye (1.7%). In eyes with diffuse diabetic macular edema and without posterior vitreous detachment, attached pos terior vitreous cortex may cause macular tangential
BRIEF REPORTS
259
traction, and vitrectomy with posterior vitreous de tachment may be effective. REFERENCES 1. Nasrallah FP, Jalkh AE, Van Coppenolle F, Kado M, Trempe CL, McMeel JW, et al. The role of the vitreous in diabetic macular edema. Ophthalmology 1988;95:1335-9. 2. Lewis H, Abrams GW, Blumenkrantz MS, Campo RV. Vitrectomy for diabetic macular traction and edema associated with posterior hyaloidal traction. Ophthalmology 1992;99: 753-9. 3. Ogura Y, Kitagawa K, Ogino N. Prospective longitudinal studies on lens changes after vitrectomy: quantitative assess ment by fluorophotometry and refractometry. Acta Soc Ophthalmol Jpn 1993;97:627-31. 4· Lewis H, Abrams GH, Foos RY. Clinicopathologic findings in anterior hyaloidal fibrovascular proliferation after vitrectomy. Am J Ophthalmol 1987;104:614-8. 5. Ferris FL, Kassof A, Bresnick GH, Bailey I. New visual acuity charts for clinical research. Am J Ophthalmol 1982;94:91-6.
Retinal Detachments by Squash Ball Accidents Harald L. J. Knorr, M.D., and Jost B. Jonas, M.D. PURPOSE: To evaluate the characteristics of reti nal detachments caused by squash ball accidents. METHODS: Twenty-six patients had a retinal de tachment after a squash ball hit their eyes. RESULTS: Characteristics of the 26 eyes with retinal detachment were large retinal tears parallel to the corneoscleral limbus located close to the ora serrata usually in the temporal superior fundus quadrant (in 14 [54%] of the 26 eyes) and in the temporal inferior quadrant (in seven eyes [27%]); primarily intact vitreous with a traumatic avulsion of the vitreous base in approxtimately one half the patients; relatively slow progression of the retinal detachment; and additional damage to the choroid and retinal pigment epithelium in the posterior fundus. The patients were young and did not have severe myopia. Reattachment of the retina was achieved in 22 (85%) of the 26 patients. In 11 patients (42%), visual acuity outcome was 20/40 or better with best correction. CONCLUSIONS: Retinal detachments after squash ball accidents show different characteris
260
tics with worse prognosis than do ordinary rhegmatogenous detachments. Protective eyewear should be worn when playing squash.
T
ENNIS AND SQUASH ARE AMONG THE MOST POPU-
lar ball games in the western hemisphere. Be cause the squash ball is smaller than the tennis ball and fits well into the anterior aperture of the orbit, accidents involving the globe occur relatively more often in squash than in tennis.1,2 This study was performed to evaluate the characteristics and the anatomic and functional outcomes of retinal detach ments as typical ocular complications of squash ball accidents. The study included 26 patients (17 males, nine females) who sustained retinal detachment as a result of squash ball injury. Only one eye of each patient was involved. Not wearing safety eyewear, these patients had experienced a contusion of their eyes when playing squash. Nine patients wore soft contact lenses, and four patients used normal spectacles. Mean age was 26.4 ± 7.8 years (mean ± S.D.; range, 8 to 42 years), and mean refractive error was —1.8 ± 0.7 diopters (range, —11.0 diopters to 0 diopters). The vitreous did not show degenerative changes that could be regarded as primarily responsible for the retinal disorder. Vitreous and retina in the fellow eyes were unremarkable. All retinal tears were breaks parallel to the corneoscleral limbus and close to the ora serrata. They had a width of less than 30 degrees in ten eyes, a width of between 30 and 60 degrees in seven eyes, and a width of more than 60 degrees in nine eyes. In the group with retinal defects of 30 degrees or less, the retina was only slightly detached. In the eyes with tears of more than 60 degrees, the retina was partially inverted with a detachment covering at least one fundus quadrant. The location of the retinal detachment was in 14 (54%) of the 26 eyes in the temporal superior fundus quadrant, in seven eyes (27%) in the temporal inferior quadrant, in three eyes (12%) in the nasal superior quadrant,
Accepted for publication March 21, 1996. Department of Ophthalmology and Eye Hospital, University Erlangen-Nürnberg. Inquiries to Jost B. Jonas, M.D., University Eye Hospital, Schwabachanlage 6, D-91054 Erlangen, Germany; fax: 49-9131854436.
AMERICAN JOURNAL OF OPHTHALMOLOGY
AUGUST 1996
Vitrectomy for Diffuse Macular Edema in Cases of Diabetic Retinopathy Naoko Tachi, M.D., and Nobuchika Ogino, M.D. PURPOSE: To ascertain the effects of posterior vitreous detachment for diffuse diabetic macular edema. METHODS: We performed vitrectomy on 58 eyes of 41 consecutive patients with diabetic macular edema without posterior vitreous detachment. Fol low-up was done at 12 months postoperatively. RESULTS: In 57 of 58 eyes after vitrectomy and posterior vitreous detachment, macular edema re solved, and diffuse fluorescein leakage disappeared in 35 of 36 eyes examined at the 12th month. Visual improvement was statistically significant (P < .0001, paired t test). CONCLUSION: In eyes with diffuse diabetic macular edema and without posterior vitreous de tachment, vitrectomy with posterior vitreous detachment may be effective.
I
N OUR EXPERIENCE, MANY EYES OF PATIENTS WITH
diabetic macular edema have demonstrated im provement after spontaneous posterior vitreous de tachment1 or vitrectomy for proliferative diabetic retinopathy. Lewis and associates2 reported vitrectomy for diabetic macular edema with a thickened and taut
Accepted for publication March 15, 1996. Department of Ophthalmology, Aichi Medical University. Inquiries to Naoko Tachi, M.D., Department of Ophthalmology, Shinseikai Toyama Hospital, 89-10 Shimowaka, Daimon-cho, Imizu, Toyama 939-02, Japan; fax: 81-766-52-2197; E-mail: [email protected]
258
vitreous membrane. The present prospective study was conducted to ascertain whether vitrectomy might be beneficial for treatment of diabetic macular edema associated with an attached premacular posterior hyaloid but without a thick vitreous membrane. We treated 58 eyes of 41 consecutive patients (21 men and 20 women) with type II diabetes mellitus and diabetic macular edema without posterior vitre ous detachment. The average age at the time of surgery was 57.5 years (range, 42 to 79 years). Eleven eyes had had grid photocoagulation and all had undergone panretinal photocoagulation. The crystal line lens was clear in 21 eyes, demonstrated mild nuclear sclerosis in 33 eyes, and showed pseudophakia in four eyes. Informed consent was obtained from each patient before surgery. We performed combined phacoemulsification and aspiration, intraocular lens implantation, and vitrectomy on 38 eyes of 28 pa tients because postoperative cataract surgery is inevi table in elderly patients,3 and the anterior vitreous cannot be removed in a phakic eye because anterior proliferation may result.4 Preoperatively, vitreous attachment over the macu lar region had been noted in all eyes under the biomicroscope, with no visible vitreous membrane on the surface of the macula. After core vitrectomy with the three-port system, posterior vitreous detachment was achieved by suction. The posterior hyaloid mem brane was then detectable with a Weiss ring, allowing resection with a vitreous cutter. The macular edema resolved in 27 (46.6%) of 58 eyes within three months, in 12 eyes (20.7%) widiin three to six months, and in 18 eyes (31.0%) from six to 12 months. Thirty-six eyes were followed up with fluorescein angiography. Preoperatively, a deep and diffuse pattern of leakage existed in the macula of the
AMERICAN JOURNAL OF OPHTHALMOLOGY
AUGUST 1996
Fig. 1 (Tachi and Ogino). Left, Preoperative fluorescein angiography of a 51-year-old woman whose visual acuity measurements are indicated in Figure 2 with an asterisk. There is diffuse fluorescein leakage and cystoid macular edema. Right, 12 months postoperatively. Both diffuse fluorescein leakage and cystoid macular edema are no longer remarkable.
20/20
20/200
2/200
POSTOPERATIVE VISUAL ACUITY
Fig. 2 (Tachi and Ogino). Visual outcome one year after vitrectomy. Best-corrected visual acuity was measured preoperatively and 12 months postoperatively. Closed circles indicates 19 eyes that underwent pars plana vitrectomy; open circles, 38 eyes that underwent com bined phacoemulsification and aspiration, intraocular lens implantation, and pars plana vitrectomy; triangle, a case in which combined surgery for the treatment of vitreous hemorrhage was performed four months after the first pars plana vitrectomy. The closed circle with an asterisk indicates an eye of which preoperative and postoperative fluorescein angiograms are shown in Fig ure 1.
VOL.122, N o . 2
36 eyes, which disappeared in 27 (75%) of 36 eyes by the sixth month and remained in only one (2.8%) of the eyes at the 12th month. The cystoid macular edema observed in 16 eyes preoperatively had disap peared in ten (62.5%) of 16 eyes at the sixth month and was observed in only three eyes (18.8%) at the 12th month (Fig. 1). At the 12th postoperative month, visual acuity had improved by more than one line in 31 (53.4%) of 58 eyes, worsened in nine eyes (15.5%) by more than one line, and had not changed in 18 eyes (31.0%) (Fig. 2). Mean logMAR, the logarithm of the mini mal angle of resolution,5 was significantly improved from the preoperative 1.029 to 0.751 at the 12th month (P < .0001, paired t test). Complications included intraoperative retinal tear formation in 12 (20.7%) of 58 eyes, vitreous hemorrhage in seven eyes (12.1%), cataract formation in six eyes (10.3%), development of an epiretinal membrane in six eyes (10.3%), and neovascular glaucomas in two eyes (3.4%), as well as rhegmatogenous retinal detach ment and another secondary glaucoma, each occur ring in one eye (1.7%). In eyes with diffuse diabetic macular edema and without posterior vitreous detachment, attached pos terior vitreous cortex may cause macular tangential
BRIEF REPORTS
259
traction, and vitrectomy with posterior vitreous de tachment may be effective. REFERENCES 1. Nasrallah FP, Jalkh AE, Van Coppenolle F, Kado M, Trempe CL, McMeel JW, et al. The role of the vitreous in diabetic macular edema. Ophthalmology 1988;95:1335-9. 2. Lewis H, Abrams GW, Blumenkrantz MS, Campo RV. Vitrectomy for diabetic macular traction and edema associated with posterior hyaloidal traction. Ophthalmology 1992;99: 753-9. 3. Ogura Y, Kitagawa K, Ogino N. Prospective longitudinal studies on lens changes after vitrectomy: quantitative assess ment by fluorophotometry and refractometry. Acta Soc Ophthalmol Jpn 1993;97:627-31. 4· Lewis H, Abrams GH, Foos RY. Clinicopathologic findings in anterior hyaloidal fibrovascular proliferation after vitrectomy. Am J Ophthalmol 1987;104:614-8. 5. Ferris FL, Kassof A, Bresnick GH, Bailey I. New visual acuity charts for clinical research. Am J Ophthalmol 1982;94:91-6.
Retinal Detachments by Squash Ball Accidents Harald L. J. Knorr, M.D., and Jost B. Jonas, M.D. PURPOSE: To evaluate the characteristics of reti nal detachments caused by squash ball accidents. METHODS: Twenty-six patients had a retinal de tachment after a squash ball hit their eyes. RESULTS: Characteristics of the 26 eyes with retinal detachment were large retinal tears parallel to the corneoscleral limbus located close to the ora serrata usually in the temporal superior fundus quadrant (in 14 [54%] of the 26 eyes) and in the temporal inferior quadrant (in seven eyes [27%]); primarily intact vitreous with a traumatic avulsion of the vitreous base in approxtimately one half the patients; relatively slow progression of the retinal detachment; and additional damage to the choroid and retinal pigment epithelium in the posterior fundus. The patients were young and did not have severe myopia. Reattachment of the retina was achieved in 22 (85%) of the 26 patients. In 11 patients (42%), visual acuity outcome was 20/40 or better with best correction. CONCLUSIONS: Retinal detachments after squash ball accidents show different characteris
260
tics with worse prognosis than do ordinary rhegmatogenous detachments. Protective eyewear should be worn when playing squash.
T
ENNIS AND SQUASH ARE AMONG THE MOST POPU-
lar ball games in the western hemisphere. Be cause the squash ball is smaller than the tennis ball and fits well into the anterior aperture of the orbit, accidents involving the globe occur relatively more often in squash than in tennis.1,2 This study was performed to evaluate the characteristics and the anatomic and functional outcomes of retinal detach ments as typical ocular complications of squash ball accidents. The study included 26 patients (17 males, nine females) who sustained retinal detachment as a result of squash ball injury. Only one eye of each patient was involved. Not wearing safety eyewear, these patients had experienced a contusion of their eyes when playing squash. Nine patients wore soft contact lenses, and four patients used normal spectacles. Mean age was 26.4 ± 7.8 years (mean ± S.D.; range, 8 to 42 years), and mean refractive error was —1.8 ± 0.7 diopters (range, —11.0 diopters to 0 diopters). The vitreous did not show degenerative changes that could be regarded as primarily responsible for the retinal disorder. Vitreous and retina in the fellow eyes were unremarkable. All retinal tears were breaks parallel to the corneoscleral limbus and close to the ora serrata. They had a width of less than 30 degrees in ten eyes, a width of between 30 and 60 degrees in seven eyes, and a width of more than 60 degrees in nine eyes. In the group with retinal defects of 30 degrees or less, the retina was only slightly detached. In the eyes with tears of more than 60 degrees, the retina was partially inverted with a detachment covering at least one fundus quadrant. The location of the retinal detachment was in 14 (54%) of the 26 eyes in the temporal superior fundus quadrant, in seven eyes (27%) in the temporal inferior quadrant, in three eyes (12%) in the nasal superior quadrant,
Accepted for publication March 21, 1996. Department of Ophthalmology and Eye Hospital, University Erlangen-Nürnberg. Inquiries to Jost B. Jonas, M.D., University Eye Hospital, Schwabachanlage 6, D-91054 Erlangen, Germany; fax: 49-9131854436.
AMERICAN JOURNAL OF OPHTHALMOLOGY
AUGUST 1996