F -X C h a n ge F -X C h a n ge c u -tr a c k N y bu to k lic Dealing with surgical cases Myth and Truth about vitrectomy .d o o .c m C m w o .d o w w w w w C lic k to bu y N O W ! PD O W ! PD c u -tr a c k What is the role of VR? Louisa Wickham Conventional Indications – Non-clearing vitreous haemorrhage • > 1 year – Tractional retinal detachment (TRD) • involving the macula – Combined TRD and RRD Theoretical Effects of Vitrectomy What is the evidence for vitrectomy? • Effects of surgery – Improve media clarity – Endolaser – Reattach retina • Effect course of disease – Remove vitreous scaffold • But.. – Reduce oxygenation by removing neovascular tufts importance of laser 1 .c F -X C h a n ge F -X C h a n ge c u -tr a c k N y bu to k lic Diabetic Retinopathy Vitrectomy Study • Patient recruitment 1976 - 1980 • 3 main components – Natural History Study – Vitrectomy for PDR – Early Vitrectomy for Vitreous Haemorrhage – TRD >4DD part of which within 30 degrees of centre of mac – TRD <4DD if focal adhesions within 30 degrees of centre of mac AND active NV or fresh haem – VA>10/50 unless vit haem – Centre of macula attached – DM • Type I 56% • Type II insulin 32% • Type II tablet 12% c u -tr a c k NN group (142 eyes) • Characteristics – – – – – Severe PDR Relatively clear vit Elevation of edge of NV consistent with partial PVD VA at least 10/50 (~6/36) DM • Type 1 72% • Type II insulin 17% • Type II tablet 11% ND group (290) • Characteristics .d o o .c m C m w o .d o w w w w w C lic k to bu y N O W ! PD O W ! PD NH • Vit haem partially or complete obscuring presumed area of NV – NH (194) • • • • VA > 10/200 Type I 55% Type II insulin 32% Type II tablet 13% – NHH (118) • • • • VA 5/200 – HM Type I 41% Type II insulin 41% Type II tablet 18% 2 .c F -X C h a n ge F -X C h a n ge c u -tr a c k N y bu to k lic .d o o .c m C m w o .d o w w w w w C lic k to bu y N O W ! PD O W ! PD c u -tr a c k Natural History • • • • Biggest drop of acuity in the first year At 2 years 35% had developed an RD 25% required vitrectomy Trend to greater visual loss with increasing activity of retinopathy • TRD - slow rate of progression – 14% extend to macula in 1 year – 21% extend to macula at 2 years Early Vitrectomy for severe PDR Early Vitrectomy for severe PDR • Inclusion • Recruitment – Extensive active NV or fibrovascular prolif – BCVA 10/200 (3/60) or better • Exclusion – – – – Previous vitrectomy Extensive rubeosis or rubeotic glaucoma RD involving macula Renal failure Early Vitrectomy for severe PDR • Vitrectomy technique – Remove all vitreous opacities – Release central traction – Removal ERMs and segmentation residual tissue – NO scatter PRP – (only allowed PRP post-op on case by case basis) – July 1979 – May 1983 – 370 eyes • Reviewed 3,6,12,18,24,36,48 months • Randomised to early vity (EV) or conventional Rx • Conventional Rx (CV) – – – – RD involving centre of macula VA dropped by 3 or more lines or VA<10/100 Severe vit haem for > 6 months with VA<5/200 Drop of VA from 10/50 to 10/100 due to traction EVS - Results • After 4 years of follow up: – Early intervention group had better VA • 44% VA >10/20 in EV cf 28% CV – Poor VA at baseline linked to poor VA at 4yr – Prior PRP assoc with better VA at 4 yr – But no laser given at time of surgery – Incr severity of NV assoc with worse endpoint in CV but this relationship neutralised with EV 3 .c F -X C h a n ge F -X C h a n ge c u -tr a c k N y bu to k lic EVS - Results .d o o .c m C m w o .d o w w w w w C lic k to bu y N O W ! PD O W ! PD c u -tr a c k Early Vitrectomy for Vitreous Haemorhage • Poorer outcome in Early gp if – Mild NV • More developed poor vision or NPL cf CV • <40% required vitrectomy • In Conventional treatment 80% eventually required vitrectomy Early Vitrectomy for Vitreous Haemorhage Early Vitrectomy for Vitreous Haemorhage Recommendations Relevance to Current Practice • Early vitrectomy if: • Severe extensive neovascularisation despite PRP • Vitreous haemorrhage precluding PRP • DRVS study completed 20 years ago • Systemic control better • Use of PRP/endolaser – PRP at time of surgery not allowed • Vitrectomy techniques have developed – Safer – Better instrumentation 4 .c F -X C h a n ge F -X C h a n ge c u -tr a c k N y bu to k lic .d o o .c m C m w o .d o w w w w w C lic k to bu y N O W ! PD O W ! PD c u -tr a c k Moorfields Results QuickTime™ and a decompressor are needed to see this picture. • • • • • Prospective 174 consecutive vitrectomies Minimum of 4 months follow up No previous vitrectomy Ocular and systemic markers collected Methods • Technical difficulty – Grading system for vitreoretinal adhesions • Pre-existing laser – Divided into zones – Density of laser (light to heavy) • Per-operative complications Results • Ethnicity – Caucasian 60.8% – South Asia 25% – Afro-caribbean 14.2% • Type I 30% • Mean duration DM 24.1 (6.9) yrs • Age – 21% under age of 40 • 27.7% logMAR>1 on admission in BE Results Indications for Sx Non-clearing vit haem TRD affecting macula CTR/RD Recurrent vit haem TRD threatening macula Rubeosis and vit haem Uncontrolled new vessels % 43.1 32.8 11.5 6.3 4.6 1.1 0.6 5 .c F -X C h a n ge F -X C h a n ge c u -tr a c k N y bu to k lic Results • 14.4% no PRP prior to vitrectomy • Per-operative endolaser performed in 91% • Complications: – 27% posterior retinal breaks • Increased if higher VR attachment score or TRD of macula – 17.2% entry site breaks – Vitreous haem 22% – RRD 3% .d o o .c m C m w o .d o w w w w w C lic k to bu y N O W ! PD O W ! PD c u -tr a c k Results • Visual Outcomes – 74.7% improved by at least 0.3 logMAR units – 16.3% improved by less than 0.3 LMU – 9% worse by at least 0.3 LMU • Significantly better outcome if macula attached pre-op • 16 patients had acuity of <6/60 BEO at 6 months (41 pre-op) Current Indications • Vitreous Haemorrhage – Pathogenesis • Tearing neovascular tufts • PVD • Fibrovascular contraction – Early • • • • Current Indications • Tractional detachment of Fovea – Visual results disappointing • Macular ischaemia • Optic nerve ischaemia Associated retinal detachment Very dense or recurrent Rubeosis Macular oedema Current Indications • Extrafoveal TED – TRD usually starts at fibrovascular membranes at the arcades – Not an absolute indication for surgery • May progress slowly • Occasionally resolve – Surgery if • Threaten fovea • Progressing • Recurrent haemorrhage 6 .c F -X C h a n ge F -X C h a n ge c u -tr a c k N y bu to k lic .d o o .c m C m w o .d o w w w w w C lic k to bu y N O W ! PD O W ! PD c u -tr a c k Current Indications • Combined TRD and RRD – Features QuickTime™ and a H.264 decompressor are needed to see this picture. • Retina more mobile • Convex RD rather than concave • Progresses rapidly – Requires urgent intervention – Difficult to manage – Post operative reproliferation commmon Macular Oedema • Tractional – Distortion of retinal surface – Diagnosed on OCT – Post operative recovery depends on ischaemia Problems with vitrectomy • Recurrent vitreous haemorrhage • Anterior hyaloidal proliferation • Diffuse – Controversial as to benefit if no traction – ? Increased oxygenation • Fibrinoid syndrome What is the future? • Earlier intervention? • Anti-VEGF and PDR QuickTime™ and a H.264 decompressor are needed to see this picture. – Associated with TRD • Hyaluronidase (Vitrase) – Reduction in vitreous haemorrhage density – Not sufficient to aid completion of PRP – ? Use in traction 7 .c F -X C h a n ge F -X C h a n ge c u -tr a c k N y bu to k lic .d o o .c m C m w o .d o w w w w w C lic k to bu y N O W ! PD O W ! PD c u -tr a c k “ one in seven vitrectomies restore sight to a blind person” 8 .c
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