The triple procedure is more effective in lowering intraocular pressure compared to phacoemulsification and trabecular aspiration alone in pseudoexfoliation glaucoma.
A retrospective study is reported on 106 eyes with proliferative diabetic retinopathy, treated by vitrectomy and silicone oil injection. Indications were traction detachment in 91 eyes and nonclearing rebleeding in 15 eyes; 31 eyes had previously had vitrectomy. Anatomical success was obtained at the end surgery in 91 eyes, and after a minimum follow-up of 6 months in 68 eyes (64%). Functional results were as follows: satisfactory visual acuity (0.5-0.05) in 23 eyes (22%), ambulatory vision (0.03-CF) in 14 eyes (13%), HM-LP in 54 eyes (51%), and NLP in 15 eyes (14%). The functional results are limited by recurrent detachments due to characteristic reproliferations under the silicone bubble or by ischemic diabetic angiopathy in the attached retina. A positive effect of silicone oil is demonstrated in the reduction of preexisting or postoperatively new iris neovascularization and in preventing postoperative rebleeding.
The updated German clinical practice guidelines (second edition) describe the consensus recommendations for prevention and treatment of retinal complications secondary to diabetes. According to the updated numbers on epidemiology a further increase of persons affected is expected. The prevalence of diabetic retinopathy is estimated to be 9-16 % in type 2 diabetes and 24-27 % in type 1 diabetes. A prolongation of the screening interval from 1 to 2 years is recommended for those patients with a lower risk of progression, when retinopathy has not already occurred and no increased systemic risk factors are present. Standardized documentation forms are the foundation for improved communication between the disciplines. If diabetic retinopathy is present, control examinations follow the stipulations of the ophthalmologist. The guidelines define scenarios when the use of optical coherence tomography (OCT) is necessary, e. g. diagnosis and follow-up of macular edema. Besides focal and panretinal laser therapy, the efficacy and risks of intravitreal operative pharmacotherapy are discussed. Focal laser coagulation is recommended for therapy of macular edema without foveal involvement and for macular edema with foveal involvement patients should be informed about the effective alternative forms of treatment. Panretinal laser coagulation is recommended for first line treatment of proliferative diabetic retinopathy and is optional for severe non-proliferative retinopathy.
Epidemiology ! Diabetic retinopathy is a frequent microvascular complication of diabetes mellitus. Patients with Type 1 Diabetes ! ▶ Retinopathy is rare in children before puberty ▶ Up to 85 % of patients with diabetes for 25 years or more years may develop retinopathy ▶ Diabetic maculopathy is present in 15 % of patients with diabetes for more than 15 years Patients with Type 2 Diabetes ! ▶ Up to one third of patients are diagnosed as having mild retinopathy when diabetes is detected ▶ Nearly 80 % of patients develop retinopathy after 15 to 20 years ▶ Diabetic maculopathy can occur in nearly 25 % of patients Symptoms ! Diabetic retinopathy and maculopathy usually develop and progress without symptoms. Fundus screening is mandatory, since only advanced stages cause symptoms. Signs and symptoms that suggest the development of retinopathy are: ▶ sudden drop of visual acuity ▶ non-correctable drop of visual acuity If the macula is affected: ▶ impaired vision ▶ impaired colour vision ▶ blurred vision ▶ "floaters" seen in front of the eye; these are caused by vitreous haemorrhages or tractive retinal detachments. Risk Factors ! ▶ hyperglycaemia ▶ arterial hypertension ▶ diabetes duration ▶ hormonal changes (pregnancy, puberty) ▶ smoking ▶ concomitant nephropathy Early Worsening of Diabetic Retinopathy !Early worsening (euglycaemic re-entry) of retinopathy affects patients with type 1 diabetes. It is rare (< 5 % of the patients), occurs primarily during the first 12 months of metabolic improvement, and is more frequent in patients with diabetes duration > 10 years and long term poor glycaemic control (HbA1c > 10 %). It cannot be prevented by gradual improvement of HbA1c. The positive effect of improved glycaemic levels outweighs early worsening.
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