Effects of vitreoretinal operations on clinical picture of diabetic maculopathy in patients with type 2 diabetes mellitus

Iu.O. Panchenko, S.Iu. Mogilevskyy


Background. Diabetic maculopathy is one of the main reasons of central vision loss in patients with diabetic retinopathy (DR) and type 2 diabetes mellitus (DM2T). The main symptom of diabetic maculopathy is diabetic macular edema (DME). DME develops as a result of increased permeability of the hemato-opht­halmic barrier due to dysfunction of the endothelium of retina vessels. Standard treatment for DME include pharmacological, laser photocoagulation, anti-VEGF and corticosteroid therapy. For treatment of more severe and resistant to pharmacological and laser treatments, as well as to anti-VEGF therapy, an alternative treatment approach is used, in particular endotracheal vitrectomy with retinal coagulation, tamponade of the reticulum, removal of the posterior hyaloid membrane and, if necessary, internal limiting membrane (ILM) peeling. The purpose of the research is to investigate the effects of various technologies of vitreoretinal surgery on the clinical picture of diabetic maculopathy in patients with DM2T. Materials and methods. The study included 163 patients (80 men, 49.1 %, and 83 women, 50.9 %) with moderate to severe non-proliferative diabetic retinopathy (NPDR) or proliferative diabetic retinopathy (PDR), and diabetic maculopathy. Duration of DM2T was from 1 year to 30 years. Ninety-eight patients had compensated DM2T, 39 — subcompensated and 26 — decompensated. The age of the patients ranged from 42 to 75 years, median age was 64.5 ± 4.2 years. These patients were divided into two groups of observation (78 patients and 85 patients). Both groups did not differ by gender, age and stage of DR (p > 0.05). The patients in the first group underwent a three-port closed subtotal vitrectomy 25+ on the Constellation Vision System (Alcon, USA) using standard technology. The patients in the second group during the vitrectomy additionally underwent ILM peeling in the macular region with a diameter of 2.5–3.5 mm. The observation period lasted 6 months. Results. After one month of follow-up, in the first group complete resorption of DME happened in 53 eyes (67.9 %), in the second group — in 70 eyes (82.3 %), thus statistically significant (p < 0.01). In 3 eyes (3.5 %) in the group where vitrectomy was performed with ILM peeling, at the first day after the operation there were the concentric narrowing of the visual field to 10–15 degrees and central relative scotoma. After 3 months of follow-up, in the first group total resorption of DME was in 63 eyes (80.8 %), in the second — in 70 eyes (82.3 %), i.e. statistically not significant (p > 0.05). After 6 months of follow-up, the resorption frequency of DME in the first and second groups was not statistically significantly and made 76.9 % and 75.3 %, respectively (p > 0.05); visual acuity in the second group reduced in 5 eyes (5.9 %) without recurrence of DMP and DME; the frequency of DME relapse in the first group was 10.3 %, in the second — 10.6 %, thus, not statistically significant (p < 0.05). In the group of vitrectomy along with ILM peeling in 10 eyes (11.8 %) there was concentric narrowing of the vision field to 5–10° mainly in nasal meri­dians and in 5 eyes (5.9 %) there were central and paracentral relative scotomas with no relapse of DMP and DME. Conclusions. Within 1 and 3 months observation periods, vitrectomy with and without ILM peeling is an effective method of DMP treatment, characteri­zed with resorption of solid exudates, microhemorrhage and DME (60.7 % and 82.4 %; 80.8 % and 82.4 %, respectively), as well as statistically significant decrease in central macular thickness and the macular volume (p < 0.05). Relapse of DME after various technologies of the vitrectomy was observed in 6 months after the operation and made 10.3 % and 10.6 %, respectively, in groups without and with ILM peeling. ILM peeling did not provide benefits in terms of prevention of DME relapse and had worse functional results within the terms of research. ILM peeling with its diameter selection must be carried out, if medically required, taking into account both risks factors of this procedure and all well-known mechanisms of DMP and DME. Prospects for increasing the effectiveness of DMP and DME prevention are concentrated in the study of new fundamental mechanisms of their development.


diabetic maculopathy; diabetes mellitus type 2; vitrectomy


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