Pars plana vitrectomy for diabetic macular edema. Internal limiting membrane delamination vs posterior hyaloid removal. A prospective randomized trial

Abstract

BackgroundDiabetes 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.MethodForty 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.ResultsMean 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)].ConclusionVitrectomy, 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.

Transconjunctival 25-gauge pars plana vitrectomy and internal limiting membrane peeling for chronic macular edema

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Transconjunctival 25-gauge pars plana vitrectomy and internal limiting membrane peeling for chronic macular edema

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Guidelines for the Management of Diabetic Macular Edema by the European Society of Retina Specialists (EURETINA)

“…BCVA gains could be observed in both groups, but a greater improvement could be seen in patients undergoing ILM peeling. These results are in contrast with those of Hoerauf et al [132] and Bardak et al [133] who reported no significantly greater BCVA gain when ILM peeling was added to PPV. The study with the longest follow-up was conducted by Kumagai et al [134] .…”

Effect of Internal Limiting Membrane Peeling on Long-Term Visual Outcomes for Diabetic Macular Edema

“…Earlier, we reported that ILM peeling was not significantly correlated with the postoperative BCVA. 42,51 This negative finding seems to be accepted, [44][45][46][47][48][49][50]52,53 and it may apply to macular edema because of branch retinal vein occlusion, 60,61 macular vein occlusion, 62 and central retinal vein occlusion. 63 Dillinger and Mester 23 reported that discrepancies between anatomical and functional results after ILM removal in chronic DME were likely caused by structural changes of the macula due to the longstanding edema.…”

Transconjunctival 25-gauge pars plana vitrectomy and internal limiting membrane peeling for chronic macular edema

“……”

“……”

Guidelines for the Management of Diabetic Macular Edema by the European Society of Retina Specialists (EURETINA)

“…BCVA gains could be observed in both groups, but a greater improvement could be seen in patients undergoing ILM peeling. These results are in contrast with those of Hoerauf et al [132] and Bardak et al [133] who reported no significantly greater BCVA gain when ILM peeling was added to PPV. The study with the longest follow-up was conducted by Kumagai et al [134] .…”

Effect of Internal Limiting Membrane Peeling on Long-Term Visual Outcomes for Diabetic Macular Edema

“…Earlier, we reported that ILM peeling was not significantly correlated with the postoperative BCVA. 42,51 This negative finding seems to be accepted, [44][45][46][47][48][49][50]52,53 and it may apply to macular edema because of branch retinal vein occlusion, 60,61 macular vein occlusion, 62 and central retinal vein occlusion. 63 Dillinger and Mester 23 reported that discrepancies between anatomical and functional results after ILM removal in chronic DME were likely caused by structural changes of the macula due to the longstanding edema.…”

Transconjunctival 25-gauge pars plana vitrectomy and internal limiting membrane peeling for chronic macular edema

“……”

“……”

Guidelines for the Management of Diabetic Macular Edema by the European Society of Retina Specialists (EURETINA)

“…BCVA gains could be observed in both groups, but a greater improvement could be seen in patients undergoing ILM peeling. These results are in contrast with those of Hoerauf et al [132] and Bardak et al [133] who reported no significantly greater BCVA gain when ILM peeling was added to PPV. The study with the longest follow-up was conducted by Kumagai et al [134] .…”

Effect of Internal Limiting Membrane Peeling on Long-Term Visual Outcomes for Diabetic Macular Edema

“…Earlier, we reported that ILM peeling was not significantly correlated with the postoperative BCVA. 42,51 This negative finding seems to be accepted, [44][45][46][47][48][49][50]52,53 and it may apply to macular edema because of branch retinal vein occlusion, 60,61 macular vein occlusion, 62 and central retinal vein occlusion. 63 Dillinger and Mester 23 reported that discrepancies between anatomical and functional results after ILM removal in chronic DME were likely caused by structural changes of the macula due to the longstanding edema.…”