Dealing with surgical cases What is the role of VR? Conventional Indications

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Dealing with surgical cases
Myth and Truth about vitrectomy
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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
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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%
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NN group (142 eyes)
• Characteristics
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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
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NH
• Vit haem partially or complete obscuring presumed area of
NV
– NH (194)
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VA > 10/200
Type I 55%
Type II insulin 32%
Type II tablet 13%
– NHH (118)
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VA 5/200 – HM
Type I 41%
Type II insulin 41%
Type II tablet 18%
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Natural History
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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
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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)
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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
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EVS - Results
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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
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Moorfields Results
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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
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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%
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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
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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
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Current Indications
• Combined TRD and RRD
– Features
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• 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
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– Associated with TRD
• Hyaluronidase (Vitrase)
– Reduction in vitreous haemorrhage density
– Not sufficient to aid completion of PRP
– ? Use in traction
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“ one in seven vitrectomies
restore sight to a blind person”
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