title: Triple therapy: Phaco-vitrectomy with ILM peeling, retinal endophotocoagulation, and intraoperative use of bevacizumab for diffuse diabetic macular edema.
abstract: BACKGROUND
  The aim of this study was to evaluate the visual acuity and structural outcomes of combined phacovitrectomy with ILM peeling, retinal endophotocoagulation and use of bevacizumab in patients with diffuse diabetic macular edema (DDME).
  
  
  METHODS
  In this prospective, nonrandomized, interventional study we included 29 eyes of 26 patients with DDME. The best-corrected visual acuity (BCVA) and central retinal thickness and volume (CRT and CRV) were recorded at 4, 8, 12, and 16 months after surgery.
  
  
  RESULTS
  The mean preoperative BCVA was 0.74±0.36 logMAR (0.3-1.5) and improved finally to 0.4±0.24 logMAR (-0.1-1.0) p=0.000006. The mean preoperative CRT in the 1mm zone was 516±184 microm (256-950) and decreased postoperatively at the last control to 237±75 microm (117-489) p=0.000003. The mean preoperative CRV in the 1mm zone was 0.39±0.14 microL (0.19-0.74) and decreased postoperatively at the last control to 0.17±0.06 microL (0.09-0.36) p=0.000003. The mean preoperative CRT in the 6 mm zone was 407±105 microm (279-640) and decreased postoperatively at the last control to 282±40 µm (212-380) p=0.000004. The mean preoperative CRV in the 6 mm zone was 11.4±2.9 microL (7.85-17.93) and decreased postoperatively at the last control to 7.92±1.0 microL (5.62-10.97) p=0.000003. The 23 (79.3%) eyes showed improvement in BCVA ≥0.2 logMAR, 5 (17.2%) eyes improvement or stabilization of BCVA and 1(3.5%) eye deterioration. Preoperative BCVA was a positive factor for prognosis of BCVA at 12th month follow-up (b=0.42; p=0.006), while the negative factors were: previous panretinal photocoagulation (b=-0.24; p=0.04), presence of vitreomacular traction (b=-0.29; p=0.02) and preoperative CRT in the 1000 microm zone (b=-0.24; p=0.07). A greater visual acuity improvement occurred in eyes with worse baseline visual acuity (b=-1.01; p=0.00001). The presentation of vitreomacular traction (b=-0.38; p=0.02), previous panretinal photocoagulation (b=-0.31, p=0.04) and greater preoperative CRT in the 1000 µm zone (b=-0.31; p=0.07) were negative factors for visual improvement.
  
  
  CONCLUSIONS
  This combined treatment resulted in improvement or stabilization of BCVA and decrease of CRT and CRV. Larger comparative studies are necessary to establish the real impact of this therapeutic approach.
authors.affiliation: Department of Ophthalmology, Military Institute of Medicine in Warsaw, Warsaw, Poland. jrobaszkiewicz@wim.mil.pl
authors.forename: Jacek
authors.initials: J
authors.lastname: Robaszkiewicz
authors.forename: Katarzyna
authors.initials: K
authors.lastname: Chmielewska
authors.forename: Małgorzata
authors.initials: M
authors.lastname: Figurska
authors.forename: Joanna
authors.initials: J
authors.lastname: Wierzbowska
authors.forename: Andrzej
authors.initials: A
authors.lastname: Stankiewicz
mesh_terms: D000328:Adult; D000368:Aged; D020533:Angiogenesis Inhibitors / Q000627:therapeutic use; D061067:Antibodies, Monoclonal, Humanized / Q000008:administration & dosage / Q000627:therapeutic use*; D000068258:Bevacizumab; D003131:Combined Modality Therapy; D003930:Diabetic Retinopathy / Q000150:complications / Q000188:drug therapy* / Q000503:physiopathology / Q000601:surgery*; D005260:Female; D006801:Humans; D007430:Intraoperative Care; D017075:Laser Coagulation; D008269:Macular Edema / Q000150:complications / Q000188:drug therapy* / Q000503:physiopathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D011182:Postoperative Care; D011300:Preoperative Care; D012044:Regression Analysis; D012160:Retina / Q000601:surgery; D014792:Visual Acuity; D014821:Vitrectomy
chemical_list: D020533:Angiogenesis Inhibitors; D061067:Antibodies, Monoclonal, Humanized; D000068258:Bevacizumab