Authors
Martynov A.O.2, Faizrakhmanov R.R.1, 2, Pavlovskii O.A.1, 2, Daloglanyan A.A.1, Lukinykh M.A.3
1 Institute of Advanced Training of Physicians N.I. Pirogov National Medical Surgical Center Moscow
2 Pirogov National Medical and Surgical Center, Moscow
3 Ophthalmological center «Vision», Moscow
Abstract
Anti-angiogenic injections are currently established as the «gold standard» for treating diabetic macular edema (DME). Vitreoretinal surgery is indicated in cases involving an epiretinal membrane or vitreoretinal traction syndrome. Some physicians consider it feasible to perform vitrectomy with the removal of the internal limiting membrane in patients with this condition.
The objective of this study is to assess changes in the morphofunctional parameters of the retina in patients with resistant forms of DME who have undergone surgical intervention. At the N.I. Pirogov National Medical and Surgical Center, 75 patients diagnosed with DME unresponsive to conservative therapy (anti-vascular proliferation therapy, retinal laser coagulation) were operated on. All patients were divided into three groups based on the type of intervention.
Evaluation of best-corrected visual acuity after surgery revealed a statistically significant improvement in this parameter among patients in the second and third groups compared to those in the first group six months post-operation. Patients in the third group showed a notable reduction in retinal thickness in the foveal area one month after the intervention. A significant decrease in edema was observed in patients from the second and third groups compared to those in the first group over the period from one month to one year. When assessing light sensitivity, a significant improvement in parameters was noted in patients from the second and third groups compared to the data from the first group one week after the surgery.
The results confirm the high effectiveness of vitreoretinal surgical intervention in patients with resistant diabetic macular edema, affirming the possibility of selecting a surgical approach.
Keywords: vitrectomy, diabetic macular edema, membrane peeling, submacular surgery, BSS.
References
1. Tan GS, Cheung N, Simó R, Cheung GC, Wong TY. Diabetic macular oedema. Lancet Diabetes Endocrinol. 2017 Feb;5(2):143-155. Epub 2016 Aug 3. PMID: 27496796.
2. Deissler HL, Deissler H, Lang GE. Inhibition of vascular endothelial growth factor (VEGF) is sufficient to completely restore barrier malfunction induced by growth factors in microvascular retinal endothelial cells. Br J Ophthalmol. 2011;95(8):1151–6.
3. Duh E, Aiello LP. Vascular endothelial growth factor and diabetes: the agonist versus antagonist paradox. Diabetes. 1999;48(10):1899–906.
4. Augustin AJ, Keller A, Koch F, Jurklies B, Dick B. [Effect of retinal coagulation status on oxidative metabolite and VEGF in 208 patients with proliferative diabetic retinopathy] Klin Monbl Augenheilkd. 2001;218(2):89–94.
5. Aiello LP, Avery RL, Arrigg PG, Keyt BA, Jampel HD, Shah ST, et al. Vascular endothelial growth factor in ocular fluid of patients with diabetic retinopathy and other retinal disorders. N Engl J Med. 1994;331(22):1480–7.
6. Gonzalez-Salinas R, Garcia-Gutierrez MC, Garcia-Aguirre G, Morales-Canton V, Velez-Montoya R, Soberon-Ventura VR, et al. Evaluation of VEGF gene polymorphisms and proliferative diabetic retinopathy in Mexican population. Int J Ophthalmol. 2017;10(1):135–9.
7. Deissler HL, Deissler H, Lang GE. Inhibition of vascular endothelial growth factor (VEGF) is sufficient to completely restore barrier malfunction induced by growth factors in microvascular retinal endothelial cells. Br J Ophthalmol. 2011;95(8):1151–6.
8. Arevalo JF, Lasave AF, Wu L, Acon D, Farah ME, Gallego-Pinazo R, et al. Intravitreal bevacizumab for diabetic macular oedema: 5-year results of the Pan-American Collaborative Retina Study group. Br J Ophthalmol. 2016; 100(12):1605–10.
9. Koskela UE, Kuusisto SM, Nissinen AE, Savolainen MJ, Liinamaa MJ. High vitreous concentration of IL-6 and IL-8, but not of adhesion molecules in relation to plasma concentrations in proliferative diabetic retinopathy. Ophthalmic Res. 2013;49(2):108–14.
10. Bhagat N, Grigorian RA, Tutela A, Zarbin MA. Diabetic macular edema: pathogenesis and treatment. Surv Ophthalmol. 2009;54(1):1–32.
11. Barile, Gaetano R., et al. The RAGE axis in early diabetic retinopathy. Investigative Opthalmology Visual Science. 2005; 46(8):2916—24
12. Ciulla TA, Amador AG, Zinman B. Diabetic retinopathy and diabetic macular edema: pathophysiology, screening, and novel therapies. Diabetes Care. 2003;26(9):2653–64.
13. Ciulla TA, Harris A, Latkany P, Piper HC, Arend O, Garzozi H, et al. Ocular perfusion abnormalities in diabetes. Acta Ophthalmol Scand. 2002;80(5):468–77.
14. Paget C, Lecomte M, Ruggiero D, Wiernsperger N, Lagarde M. Modification of enzymatic antioxidants in retinal microvascular cells by glucose or advanced glycation end products. Free Radic Biol Med. 1998;25(1):121–9. pmid: 9655530.
15. Early photocoagulation for diabetic retinopathy. ETDRS report number 9. Early Treatment Diabetic Retinopathy Study Research Group. Ophthalmology. 1991 May;98(5 Suppl):766-85.
16. Liberski S, Wichrowska M, Kocięcki J. Aflibercept versus Faricimab in the Treatment of Neovascular Age-Related Macular Degeneration and Diabetic Macular Edema: A Review. Int J Mol Sci. 2022 Aug 20;23(16):9424.
17. Massin P, Bandello F, Garweg JG, Hansen LL, Harding SP, Larsen M, et al. Safety and efficacy of ranibizumab in diabetic macular edema (RESOLVE Study): a 12-month, randomized, controlled, double-masked, multicenter phase II study. Diabetes Care. 2010;33(11):2399–405.
18.Sahni J, Patel SS, Dugel PU, Khanani AM, Jhaveri CD, Wykoff CC, Hershberger VS, Pauly-Evers M, Sadikhov S, Szczesny P, Schwab D, Nogoceke E, Osborne A, Weikert R, Fauser S. Simultaneous Inhibition of Angiopoietin-2 and Vascular Endothelial Growth Factor-A with Faricimab in Diabetic Macular Edema: BOULEVARD Phase 2 Randomized Trial. Ophthalmology. 2019 Aug;126(8):1155-1170.
19. Agarwal D, Chawla R, Varshney T, Shaikh N, Chandra P, Kumar A. Managing vitreoretinal surgeries during COVID-19 lockdown in India: Experiences and future implications. Indian J Ophthalmol. 2020 Oct;68(10):2126-2130.
20. Polizzi S, Mahajan VB. Intravitreal Anti-VEGF Injections in Pregnancy: Case Series and Review of Literature. J Ocul Pharmacol Ther. 2015 Dec;31(10): 605-10.
21. Agarwal D, Kumar A. Managing intravitreal injections in adults in COVID-19 and post-COVID-19 era- Initial experiences. Indian J Ophthalmol. 2020 Jun;68(6):1216-1218.
22. Pavlovskiy O.A., Fayzrachmanov R.R., Egorova N.S., Pyankova M.A. Morphofunctional Results of Surgical Treatment of Epiretinal Fibrosis: A Comparative Analysis. Reflection. – 2023. – No. 2(16). – pp. 49-53. (In Russ.)
23. Diabetic Retinopathy Clinical Research Network Writing Committee. Bressler S.B., Edwards A.R., et al. Vitrectomy outcomes in eyes with diabetic macular edema and vitreomacular traction. Ophthalmology. 2021;132:1113–1122.
24. Fayzrahmanov R.R., Pavlovskiy O.А., Larina E.A. The method of closure of macular holes with a partial peeling of the internal limiting membtane: comparative analisis. Medline.ru, vol. 20, art. 17 (pp. 187-200), 2019. (In Russ.)
25. Hagenau F, Vogt D, Ziada J, Guenther SR, Haritoglou C, Wolf A, Vitrectomy for diabetic macular edema: optical coherence tomography criteria and pathology of the vitreomacular interface. Am J Ophthalmol. 2019;200:34–46.
26. Abdel Hadi AM. Evaluation of Vitrectomy with Planned Foveal Detachment as Surgical Treatment for Refractory Diabetic Macular Edema with or without Vitreomacular Interface Abnormality. J Ophthalmol. 2018 May 7;2018:9246384.
27. Vikas SJ, Agarwal D, Seth S, Kumar A, Kumar A. Comparison of anatomical and functional outcomes of vitrectomy with internal limiting membrane peeling in recalcitrant diabetic macular edema with and without traction in Indian patients. Indian J Ophthalmol. 2021 Nov;69(11):3297-3301.
28. Ranno S, Vujosevic S, Mambretti M, Metrangolo C, Alkabes M, Rabbiolo G, Govetto A, Carini E, Nucci P, Radice P. Role of Vitrectomy in Nontractional Refractory Diabetic Macular Edema. J Clin Med. 2023 Mar 15;12(6):2297.
29. Iglicki M, Lavaque A, Ozimek M, Negri HP, Okada M, Chhablani J, Busch C, Loewenstein A, Zur D. Biomarkers and predictors for functional and anatomic outcomes for small gauge pars plana vitrectomy and peeling of the internal limiting membrane in naïve diabetic macular edema: the VITAL study. PLoS One. 2018;13(7):e0200365.
30. Bosov, E.D., Kalinin M.E., Karpov G.O., Bogdanova V.A. Influence of changes in the retinal pigment layer on morphofunctional results after surgery for submacular hemorrhages. Bulletin of Pirogov National Medical Surgical Center 17, no. s4 (2022): 25–27. (In Russ.)
31. Takagi, Hitoshi, Atsushi Otani, Junichi Kiryu, and Yuichiro Ogura. “New Surgical Approach for Removing Massive Foveal Hard Exudates in Diabetic Macular Edema.” Ophthalmology 106, no. 2 (February 1999): 249–57.