2020–2021 BCSC Basic and Clinical Science Course™
12 Retina and Vitreous
Part III: Selected Therapeutic Topics
Chapter 20: Vitreoretinal Surgery and Intravitreal Injections
Vitrectomy for Complications of Diabetic Retinopathy
Advances in vitreoretinal surgical techniques have facilitated earlier surgical intervention in patients with diabetic retinopathy, with reduced surgical morbidity and decreased surgical duration. These advances include the routine use of intraocular endolasers, widefield noncontact viewing systems, smaller-gauge surgical instrumentation, bimanual surgical techniques, and perioperative anti-VEGF injections. In addition, the use of anti-VEGF agents prior to vitrectomy for proliferative diabetic retinopathy (PDR) reduces intraoperative bleeding as well as surgical duration, the incidence of intraoperative retinal breaks, and the number of endodiathermy applications. Pre-operative use of anti-VEGF agents can help reduce intraoperative bleeding but can lead to traction retinal detachment if surgery is significantly delayed following the injection.
Vitreous hemorrhage is a common complication in patients with PDR. Vitrectomy is indicated when a vitreous hemorrhage fails to clear spontaneously after approximately 4 weeks to 3 months; the timing of the surgery is determined by the surgeon’s preference and the patient’s visual requirements. Possible indications for more prompt intervention include monocularity, bilateral vitreous hemorrhages or ultrasonic evidence of a retinal tear, underlying rhegmatogenous retinal detachment, or tractional retinal detachment that threatens the macula. In the absence of ophthalmoscopic visualization, serial ultrasonography helps the clinician assess the anatomical condition of the retina. If surgery is indicated, treatment involves a pars plana vitrectomy with removal of vitreous hemorrhage (Video 20-4) and release of the hyaloid from fronds of retinal neovascularization. Vitreoretinal traction at the optic nerve head and along the arcade vessels, if present, is addressed at the time of surgery, along with any macular ERMs. Complete panretinal photocoagulation and hemostasis should generally be achieved during the procedure. To prevent bleeding or rebleeding, the eye may be filled with air or a short-acting gas to tamponade possible bleeding sites.
Vitrectomy for vitreous hemorrhage.
Courtesy of Colin A. McCannel, MD.
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.