Pars plana vitrectomy for diabetic macular edema. Internal limiting membrane delamination vs posterior hyaloid removal. A prospective randomized trial.
BACKGROUND
Diabetes mellitus, as well as subsequent ocular complications such as cystoid macular edema (CME), are of fundametal socio-economic relevance. Therefore, we evaluated the influence of internal limiting membrane (ILM) removal on longterm morphological and functional outcome in patients with diabetes mellitus (DM) type 2 and chronic CME without evident vitreomacular traction.


METHODS
Forty eyes with attached posterior hyaloid were included in this prospective trial and randomized intraoperatively. Prior focal (n = 31) or panretinal (n = 25) laser coagulation was permitted. Group I (n = 19 patients) underwent surgical induction of posterior vitreous detachment (PVD), group II (n = 20 patients) PVD and removal of the ILM. Eleven patients with detached posterior hyaloid (group III) were not randomized, and ILM removal was performed. One eye had to be excluded from further analysis. Examinations included ETDRS best-corrected visual acuity (BCVA), fluorescein angiography (FLA) and OCT at baseline, 3 and 6 months postoperatively. Main outcome measure was BCVA at 6 months, secondary was foveal thickness.


RESULTS
Mean BCVA over 6 months remained unchanged in 85% of patients of group II, and decreased in 53% of patients of group I. Results were not statistically significant different [group I: mean decrease log MAR 95% CI (0.06; 0.32), group II: (-0.02; 0.11)]. OCT revealed a significantly greater reduction of foveal thickness following PVD with ILM removal [group I: mean change: 95% CI (-208.95 μm; -78.05 μm), group II: (-80.90 μm: +59.17 μm)].


CONCLUSIONS
Vitrectomy, PVD with or without ILM removal does not improve vision in patients with DM type 2 and cystoid diabetic macular edema without evident vitreoretinal traction. ILM delamination shows improved morphological results, and appears to be beneficial in eyes with preexisting PVD.
University Eye Clinic, Georg-August-University, Robert-Koch-Str. 40, 37075, Goettingen, Germany. hanshoerauf@med.uni-goettingen.de
Hans
H
Hoerauf
Anne
A
Brüggemann
Manuela
M
Muecke
Julia
J
Lüke
Maya
M
Müller
Einar
E
Stefánsson
Hans-Peter
HP
Hammes
Claudia
C
Weiss
D000368:Aged; D001485:Basement Membrane / Q000378:metabolism / Q000601:surgery*; D015415:Biomarkers / Q000378:metabolism; D003924:Diabetes Mellitus, Type 2 / Q000150:complications; D003930:Diabetic Retinopathy / Q000503:physiopathology / Q000601:surgery*; D005260:Female; D005451:Fluorescein Angiography; D006801:Humans; D007124:Immunoenzyme Techniques; D007208:Indocyanine Green; D008269:Macular Edema / Q000503:physiopathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D041623:Tomography, Optical Coherence; D016896:Treatment Outcome; D014792:Visual Acuity / Q000502:physiology; D014821:Vitrectomy; D014822:Vitreous Body / Q000601:surgery*
D015415:Biomarkers; D007208:Indocyanine Green
Cell. 2006 Jan 27;124(2):275-86
16413606
Am J Ophthalmol. 2005 Apr;139(4):638-52
15808159
Am J Ophthalmol. 1996 Aug;122(2):258-60
8694095
Am J Ophthalmol. 1996 Apr;121(4):405-13
8604734
Retina. 2002 Dec;22(6):759-67
12476103
Invest Ophthalmol Vis Sci. 2005 Jul;46(7):2592-600
15980253
Invest Ophthalmol Vis Sci. 1999 Jul;40(8):1855-9
10393061
Klin Monbl Augenheilkd. 2005 Aug;222(8):643-8
16118745
Am J Ophthalmol. 2002 Aug;134(2):214-9
12140028
Br J Ophthalmol. 1999 Jan;83(1):12-4
10209427
Ophthalmology. 2006 Sep;113(9):1533-8
16828501
Graefes Arch Clin Exp Ophthalmol. 2005 Jan;243(1):20-5
15290152
Nature. 2000 Apr 13;404(6779):787-90
10783895
Am J Ophthalmol. 2005 Mar;139(3):447-54
15767052
Lancet. 2001 Apr 14;357(9263):1191-4
11323066
Ophthalmology. 1992 May;99(5):753-9
1594222
Eur J Ophthalmol. 2004 Mar-Apr;14(2):137-43
15134111
Retina. 2007 Jun;27(5):557-66
17558316
Am J Ophthalmol. 2000 Aug;130(2):178-86
11004291
Ophthalmology. 1988 Oct;95(10):1335-9
3226682
Am J Ophthalmol. 2006 Oct;142(4):660-8
17011860
Ophthalmology. 1997 Mar;104(3):473-8
9082275
Ophthalmology. 1987 Jul;94(7):761-74
3658348
Lab Invest. 1996 Sep;75(3):325-38
8804356
Eur J Ophthalmol. 2006 Jul-Aug;16(4):566-72
16952096
Int Ophthalmol. 2005 Feb-Apr;26(1-2):3-8
16786177
Retina. 2006 Nov-Dec;26(9):999-1005
17151486
Ophthalmology. 2004 Feb;111(2):226-30
15019367
Am J Ophthalmol. 2005 Aug;140(2):295-301
16023067
Acta Ophthalmol Scand. 2001 Oct;79(5):435-40
11594975
Retina. 2000;20(2):126-33
10783944
Ophthalmology. 2005 Oct;112(10):1747-57
16154196
Diabetologia. 1999 Jun;42(6):728-36
10382593
Retina. 2000;20(2):220-2
10783963
Retina. 2005 Apr-May;25(3):311-6
15805908
Graefes Arch Clin Exp Ophthalmol. 2001 Apr;239(4):264-70
11450490
Graefes Arch Clin Exp Ophthalmol. 2000 Jan;238(1):8-18
10664046
J Ocul Pharmacol Ther. 2006 Jun;22(3):200-7
16808682
Arch Ophthalmol. 1991 Jul;109(7):1005-11
2064554
Ophthalmic Surg Lasers Imaging. 2004 Jul-Aug;35(4):292-7
15305552
Retina. 2008 Mar;28(3):410-9
18327132
Ger J Ophthalmol. 1995 Jan;4(1):47-51
7728110
Graefes Arch Clin Exp Ophthalmol. 2007 Mar;245(3):360-8
17093998
Graefes Arch Clin Exp Ophthalmol. 2004 Aug;242(8):630-7
15221304
Graefes Arch Clin Exp Ophthalmol. 2009 Feb;247(2):147-63
19034481
Retina. 2006 Jan;26(1):5-13
16395132
Graefes Arch Clin Exp Ophthalmol. 2004 Apr;242(4):273-8
15042375
Invest Ophthalmol Vis Sci. 1990 Feb;31(2):284-9
2303330