![Page 1: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/1.jpg)
Surgical Management of Diabetic Retinopathy
Thomas Aaberg Jr. M.D.Retina Specialist of Michigan
Michigan State University
![Page 2: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/2.jpg)
Management of complications from Proliferative diabetic
retinopathy
Pars plana vitrectomy is the procedure of choice for vitreous hemorrhage and tractional retinal detachment
![Page 3: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/3.jpg)
Pars plana vitrectomy-Indications
Persistent vitreous hemorrhage Tractional/combined rhegmatogenous
retinal detachment Premacular hemorrhage Bridging retinal fibrosis Persistent diabetic macular edema
![Page 4: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/4.jpg)
Pathogenesis Review:Surgical Intervention for TRD
Hypoxia and angiogenic factors, eg. VEGF
Neovascular and fibrovascular proliferation that extends from the retina into the vitreous cavity
Cycle of proliferation and regression along the posterior margin of capillary non-perfusion
Vitreous Surgery. In Michels RG, Wilkinson CP and Rice TA eds. Retinal Detachment. St. Louis, 1990, Mosby, p. 814
![Page 5: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/5.jpg)
Pathogenesis Review:Surgical Intervention for TRD
Neovascular proliferation usually begins: at the optic nerve along temporal
vascular arcades mid-periphery at the
posterior margin of capillary non-perfusion
Vitreous Surgery. In Michels RG, Wilkinson CP and Rice TA eds. Retinal Detachment. St. Louis, 1990, Mosby, p. 814
![Page 6: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/6.jpg)
Pathogenesis Review:Proliferative Diabetic Retinopathy
Initially “bare” Later, fibrous tissue appears Vitreoretinal adhesions form Cycle of proliferation and
regression
![Page 7: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/7.jpg)
Pathogenesis Review:Surgical Intervention for TRD
Growth of fibrovascular tissue is dependent on posterior vitreous surface Changes in vitreous occur, often resulting
in partial posterior vitreous detachment Vitreous typically remains attached at
anterior retina/vitreous base and at each area of fibrovascular proliferation
Vitreous Surgery. In Michels RG, Wilkinson CP and Rice TA eds. Retinal Detachment. St. Louis, 1990, Mosby, p. 815
![Page 8: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/8.jpg)
Pathogenesis Review:Surgical Intervention for TRD
Contraction of fibrovascular tissue growing along posterior vitreous surface can cause vitreous changes and antero-posterior traction.
In the absence of vitreous separation, widespread adhesions to the retinal surface may develop
Vitreous Surgery. In Michels RG, Wilkinson CP and Rice TA eds. Retinal Detachment. St. Louis, 1990, Mosby, p. 816
![Page 9: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/9.jpg)
Pathogenesis Review:Surgical Intervention for TRD
Contraction forces may lead to: Hemorrhage into vitreous
gel or preretinal space Tractional retinal
detachment (TRD) Distortion of retina/macula Antero-posterior and
tangential traction
Traction on the optic nerve Retinal tears
Vitreous Surgery. In Michels RG, Wilkinson CP and Rice TA eds. Retinal Detachment. St. Louis, 1990, Mosby, p. 816
![Page 10: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/10.jpg)
![Page 11: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/11.jpg)
![Page 12: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/12.jpg)
Surgical Management
A review of the past,And where we are today.
![Page 13: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/13.jpg)
Surgical Intervention for TRD
PurposeReverse pre-existing complications
causing visual lossAlter course of retinopathy and remove
posterior vitreous surface
Vitreous Surgery. In Michels RG, Wilkinson CP and Rice TA eds. Retinal Detachment. St. Louis, 1990, Mosby, p. 816
![Page 14: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/14.jpg)
Surgical Intervention for TRD
Posterior vitreous surface is of great importance in pathogenesis and complications of proliferative diabetic retinopathy and must be addressed during vitreous surgery
Vitreous Surgery. In Michels RG, Wilkinson CP and Rice TA eds. Retinal Detachment. St. Louis, 1990, Mosby, p. 816
![Page 15: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/15.jpg)
Surgical Intervention for TRD
Surgical objectivesRemove visually significant opacitiesExcise posterior hyaloidRemove and/or segment preretinal or
epiretinal fibrovascular tissue Identify & treat retinal breaksHemostasisPanretinal photocoagulationTamponade as needed
Vitreous Surgery. In Michels RG, Wilkinson CP and Rice TA eds. Retinal Detachment. St. Louis, 1990, Mosby, p. 816
![Page 16: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/16.jpg)
DDiabetic
RRetinopathy
VVitrectomy
SStudyA MultiA Multi--Center Collaborative Clinical TrialCenter Collaborative Clinical TrialSupported by Contracts fromSupported by Contracts fromThe National Eye Institute The National Eye Institute
PortlandPortland
San FranciscoSan Francisco
Los AngelesLos Angeles
MinneapolisMinneapolis
MadisonMadisonChicagoChicago
MilwaukeeMilwaukee
DetroitDetroit
AlbanyAlbanyBostonBoston
New YorkNew YorkPhiladelphiaPhiladelphia
BaltimoreBaltimore
DurhamDurham
AtlantaAtlanta
MiamiMiami
![Page 17: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/17.jpg)
More rapid recovery of useful vision (important if fellow eye
has poor vision)
Greater chance for recovery of good vision (at least Type I DM
who were younger and had more severe PDR)
Suggestive increase in frequency of NLP in Type II and mixed
DM groups (older patients with less PDR)
Early Vitrectomy in Eyes with Recent Severe Diabetic Vitreous
Hemorrhage
![Page 18: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/18.jpg)
Diabetic Retinopathy Vitrectomy Study
Eyes (n = 370) with fibrovascular proliferation and 20/400 or better VAResults: 20/40 or better VA at 4 yearsEarly surgery: 44% eyesDeferred surgery: 28% eyes
Early Vitrectomy for Severe Proliferative Diabetic Retinopathy in Eyes with Useful Vision. Results of a Randomized Trial--. Diabetic Retinopathy Vitrectomy Study (DRVS) report #3. Ophthalmol 1988; 95(10):1307-1320
![Page 19: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/19.jpg)
Results of Vitrectomy for diabetic TRD involving macula
Improved VA: 26% - 72% cases
Vitreous Surgery. In Michels RG, Wilkinson CP and Rice TA eds. Retinal Detachment. St. Louis, 1990, Mosby, p. 824-825
![Page 20: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/20.jpg)
Results of Vitrectomy for combined diabetic TRD and rhegmatogenous
detachment
Retinal reattachment: 80%
Improved Vision: 50%
Rates of success can vary based on patient population, pathology and access to health care
Vitreous Surgery. In Michels RG, Wilkinson CP and Rice TA eds. Retinal Detachment. St. Louis, 1990, Mosby, p. 825Photo courtesy of Edgar L. Thomas, MD
![Page 21: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/21.jpg)
Diabetic Vitrectomy: Advanced Surgical Techniques
![Page 22: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/22.jpg)
Step 1: Pre-operative Care
![Page 23: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/23.jpg)
Advanced Diabetic Vitrectomy Begins Pre-operatively
Maximize systemic health/stability Concentrate on renal statusWork with primary care physician,
endocrinologist, nephrologist Properly educate patient Pathophysiology Extent of disease Proper patient expectations
![Page 24: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/24.jpg)
Immediate Pre-Operative Anti-VEGF … Yes or No Literature supporting
both pro and con Personally I use IF: I know the patient will be
compliant I know the surgical case is
a GO There is active NV not just
traction or hemorrhage.
![Page 25: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/25.jpg)
Why be concerned about anti-VEGF use?
Immediate concern: Delayed surgery may
lead to progressive severe vitreoretinal contraction
Longer term concern: Rebound proliferation
once anti-VEGF effect dissipates.
![Page 26: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/26.jpg)
Step 2: Surgical Planning
Game changing advances in surgical instrumentation.
![Page 27: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/27.jpg)
Surgical Planning/Decisions
Anesthesia: General vs Local Gauge: 20 vs 23 vs 25 vs 27 Lens disposition Pseudophakic Phakic Unencumbered view of pathology Compromises view Keep or remove the lens with or without an IOL
Bimanual versus “uni”-manual approach
![Page 28: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/28.jpg)
Chosen Surgical Gauge was largely dictated by number of available
instruments Vitrectomy probesHigh speed cuttersDifferent edge profiles
20 gauge
20 gauge
25 gauge
25 gauge
![Page 29: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/29.jpg)
Advances in Surgical Instrumentation20 gauge
Forceps
![Page 30: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/30.jpg)
Advances in Surgical Instrumentation20 gauge
Scissors
![Page 31: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/31.jpg)
Advances in Surgical Instrumentation20 gauge
Illuminated instruments
![Page 32: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/32.jpg)
Currently nearly all instruments are available in 25 and 23 gauges
Photos courtesy of E.Thomas, MD and Alcon
25 gauge - system
![Page 33: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/33.jpg)
Advances in Surgical Instrumentation25 gauge - system
Vitrectomy cutter
Trochar canula inserter
Canula
InstrumentsPhotos courtesy of E.Thomas, MD and Alcon
![Page 34: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/34.jpg)
Advances in Surgical Instrumentation
25 gauge
Forceps
Scissors
Picks
![Page 35: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/35.jpg)
Illuminated instrumentation and chandeliers … a critical advance
20 gauge chandelier and set-up Illuminates one area preferentially
Photos courtesy of Synergetics and James Andrews
![Page 36: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/36.jpg)
Illuminated instrumentation and chandeliers … a critical advance
Photos courtesy of Synergetics and James Andrews
29-gauge chandelier and Xenon light source
![Page 37: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/37.jpg)
Another critical surgical advance:Perfluorocarbon Liquid
Properties Non-toxic Clear liquid High density Low viscosity; easy
to inject and remove Visualize liquid
interface Volatility
![Page 38: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/38.jpg)
Perfluorocarbon Liquid: The Third Hand
Benefits Keep heme off
macular region Assist in dissection
and removal of posterior hyaloid Stabilize the retina
during membrane dissection and delamination
![Page 39: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/39.jpg)
Perfluorocarbon Liquid: The Third Hand
Benefits Identify residual
posterior hyaloid and membranes Drain subretinal
fluid through peripheral break Allow for
controlled retinotomies
![Page 40: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/40.jpg)
Perfluorocarbon Liquid: The Third Hand
Complications Subretinal PFC may pass through posterior
breaks with traction Residual PFC at end of surgerymore common in hemorrhages
![Page 41: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/41.jpg)
Advances in Surgical Instrumentation:Wide Angle Viewing
Contact AVI Volk
Noncontact BIOM Merlin
![Page 42: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/42.jpg)
Advances in Surgical InstrumentationWide Angle Viewing
Benefits Improved panoramic visualizationMore easily visualize extent of tractional forces Improved management of peripheral retinal
pathology Bimanual surgery Enhances phakic fluid air exchange and
placement of scatter laser treatment
![Page 43: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/43.jpg)
Step 3: Surgical Techniques
![Page 44: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/44.jpg)
Single Instrument Vitrectomy
![Page 45: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/45.jpg)
Bimanual Surgery
Endo-illumination by chandelier Single chandelier Dual chandelier Illuminated infusion cannula Illuminated instruments
![Page 46: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/46.jpg)
Surgical Intervention for TRD Surgical TechniquesVitrectomyRemove core vitreousIncise posterior vitreous surfaceRelieve A-P traction
Vitreous Surgery. In Michels RG, Wilkinson CP and Rice TA eds. Retinal Detachment. St. Louis, 1990, Mosby, p. 816-817
![Page 47: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/47.jpg)
Surgical Techniques for surface membranes
SegmentationDivide fibrovascular tissue
Vitreous Surgery. In Michels RG, Wilkinson CP and Rice TA eds. Retinal Detachment. St. Louis, 1990, Mosby, p. 816-824
![Page 48: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/48.jpg)
Surgical Techniques for surface membranes
En blocUse some posterior vitreous A-P traction
to elevate edge of fibrovascular tissue
Diagrams from Gardner TW and Blankenship GW. Proliferative diabetic retinopathy: principles and techniques of surgical treatment. In Ryan SJ ed. Retina, Bert Glaser, ed. Vol 3 Surgical Retina. St. Louis, 1994, Mosby, p. 2420-2421
![Page 49: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/49.jpg)
Surgical Techniques for surface membranes
Modified En Bloc Delamination After releasing
pathology from the vitreous base, use an instrument to induce A-P traction and create a cleavage plane.
![Page 50: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/50.jpg)
Surgical Techniques for surface membranes
Modified En Bloc Delamination Identify cleavage plane Scissors to transect
fibrovascular bridges Hemostasis Endodiathermy or
bipolar diathermy PRP Tamponade as needed
![Page 51: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/51.jpg)
Hemostasis Critical in the diabetic
patient Fibrin deposition Secondary membranes Immediate post-
operative vitreous hemorrhages
Tactics Raise intraocular
pressure Intraocular diathermy Intraocular Thrombin
![Page 52: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/52.jpg)
Surgical Intervention for TRD
First-Is it necessary? Break No-breaks
Second-Which agent? Air SF6 C3F8 Silicone oil Monocular Aphakia
![Page 53: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/53.jpg)
Tamponade
Factors relevant to tamponade agent Extent of pathology Patient
compliance/physical abilities Lens Status Monocular vs
Binocular Travel
![Page 54: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/54.jpg)
Surgical intervention for TRD
Major ComplicationsRetinal tearsRetinal detachmentPVRCataractEndophthalmitis
Vitreous Surgery. In Michels RG, Wilkinson CP and Rice TA eds. Retinal Detachment. St. Louis, 1990, Mosby, p. 825
![Page 55: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/55.jpg)
![Page 56: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/56.jpg)
Management of Tractional Retinal Detachment
Summary Tractional Retinal Detachment Pathogenesis
Surgical intervention Surgical objectives/techniques Progress in instrumentation Perfluorocarbon liquidsWide angle viewing High speed vitrectomy 25 gauge - sutureless
Pharmacotherapeutic interventions Plasmin Vitrase
![Page 57: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/57.jpg)
Premacular hemorrhage Pre-Operative Vision = CF
![Page 58: Aaberg jr surgical management for diabetic retinopathy 2014](https://reader033.vdocuments.site/reader033/viewer/2022060107/554b3a88b4c905ff268b4764/html5/thumbnails/58.jpg)
Post vitrectomy Vision = 20/30