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The goal of any treatment, laser, steroid injections or anti-VEGF injections is to reduce the swelling. Usually, a fluorescein angiogram is performed to demonstrate where the normal retinal blood vessels are leaking. Treatment can involve anywhere from a few to dozens of burns…all depending upon the number leaks. Laser treatment to the center of the macula could lead to a permanent blind spot in the vision and, therefore, is not always the best treatment for every patient. After 4-6 months, I can usually tell if the laser treatment is effective or needs to be augmented (ie.
There are a variety of treatments for diabetic macular edema.   Laser treatment is still the standard of care for treating this common condition seen with diabetic retinopathy. With cataract surgery there are often a number of challenges that need to be addressed, including co-existing macular disease. One other concern with multifocal IOLs and macular disease is the possibility of having to do more surgeries at a later time if the macular condition worsens. Without treatment, 50% of eyes with DME will lose 2 or more lines of vision within two years of diagnosis.4 Even though the incidence of DME can be reduced with systemic control of serum glucose, hypertension, and hypercholesterolemia, the need for ophthalmic treatment of DME is common. Even with the availability of multiple therapeutic agents, including intravitreal anti-VEGF agents, focal laser, and, in some selective cases, corticosteroids, refractory DME continues to challenge retina specialists around the world. In this article, we review the pathophysiological and clinical evidence that support the surgical management of DME, and we discuss how to identify appropriate candidates. This classification scheme can help in interpreting the literature and in assessing eligible patients for surgery. The pathogenesis of DME is multifactorial and includes a cascade of complex biochemical processes. Although vitrectomy may clear the vitreous of its VEGF load, one caveat is that intravitreal medications may also be cleared more quickly once the vitreous is removed. When evaluating an eye as a potential candidate for surgical intervention, one should classify DME as not only as focal or diffuse, but also by the status of the vitreous and the vitreomacular interface.
We have divided cases of DME into three major categories with five subcategories or entities (Table 1). The second category is an entity referred to as postvitrectomy taut ILM syndrome, which causes new-onset DME following diabetic vitrectomy related to tangential traction along the ILM.
The final category is recalcitrant DME without any apparent vitreomacular interface abnormalities.
Hyper-reflective (less dense than epiretinal membrane) to normal reflective ILM without vitreoretinal adhesions. Abnormal vitreomacular adhesions or proliferation, or both, start with various manifestations of PVD. If the foveal or macular separation of the posterior hyaloid does not occur, persistent traction on the area of adhesion can, in a diabetic eye, result in macular edema.
We have divided DME with abnormal vitreomacular adhesions or proliferation, or both, into three distinct entities based on both the clinical and OCT findings.
Even though we separate them into three entities, they are, in fact, a spectrum of disease.
Even though they described the majority of eyes as having a tractional macular detachment, the majority of eyes in their study had partial-thickness retinal elevations.
An additional study by Massin found that six eyes of seven patients with refractory DME and a taut hyaloid had vitreomacular traction on OCT.
Additional studies of OCT findings in patients with taut hyaloids could help shed light on the vitreoretinal interface in these patients.
The terms vitreomacular traction and vitreofoveal traction have been used to describe a clinical entity in which the posterior hyaloid detaches from the posterior retina but remains attached focally to the macula and or fovea.
The etiology is similar to taut hyaloid, and many retina specialists lump these three entities into the same group. Vitreomacular traction has similar, but less dramatic, vitreoretinal interface changes, and it is commonly diagnosed using OCT. Broad areas of multiple adhesions cause vitreomacular traction (VMT) (Figure 2), while a small area of adhesion at the fovea causes vitreofoveal traction (VFT) (Figure 3). Even though OCT findings for all three entities reveal abnormal vitreoretinal adhesions, VMT and VFT tend to have greater separation of the posterior hyaloid from the surface of the retina when compared to eyes with the classic taut hyaloids.
In 2010, the Diabetic Retinopathy Clinical Research Network published the largest series of vitrectomy for DME with VMT. At six months, they found a reduction in OCT central subfield thickness (CST) of at least 50% in 68% of patients. Each of these entities has varying degrees of vitreoretinal traction that contributes to the formation of DME, and many eyes have features of all three entities. In the future, we hope that standardized OCT interpretations of the vitreoretinal interface will become available and help determine which eyes benefit most from surgical treatment. Posterior vitreous detachment is also important in the pathogenesis of ERMs.24 In the early stages of PVD, and especially in areas of vitreoschisis, hyalocytes retained on the retinal surface can proliferate and grow onto the surface of the attached hyaloid. Postvitrectomy taut ILM is an uncommon cause of new-onset diffuse DME after diabetic vitrectomy with prior hyaloid removal.27 One can differentiate this entity from a taut posterior hyaloid and vitreomacular or vitreofoveal traction, or both, by the absence of an attached or partially attached hyaloid. It occurs more than six weeks after vitrectomy with hyaloid removal and is unresponsive to laser, corticosteroids and anti-VEGF. Optical coherence tomography shows outer retinal edema with no evidence of definite traction (Figure 5). The pathophysiology of postvitrectomy taut ILM is postulated to be from tangential traction along the ILM by contractile cellular elements. Although vitrectomy may be useful for eyes with vitreomacular interface abnormalities, the majority of eyes with refractory DME have a normal interface. Many case series have been published on the surgical treatment of DME without vitreomacular interface abnormalities.
Most studies of vitrectomy, with or without ILM peeling, for DME without abnormal vitreomacular adhesion were undertaken before the era of anti-VEGF agents and were mainly reserved for eyes unresponsive to laser treatment. One of the first studies that seemed to hold promise for this treatment was published by Gandorfer et al. Vitrectomy for the treatment of DME has been shown to benefit some eyes with mechanical causes of the edema.
In the absence of a mechanical cause for DME, vitrectomy results have been variable, with visual outcomes much less impressive than OCT results. It is not clear what role the addition of ILM peeling has in the treatment of these entities. In contrast, ILM peeling has been shown to be the treatment of choice in a small subgroup of eyes with postvitrectomy taut ILM syndrome.27 Lack of response to laser, steroids, and anti-VEGF agents is a requirement for this diagnosis.
Because most of the studies on vitrectomy for DME were undertaken before the widespread use of anti-VEGF agents, it is not known whether anti-VEGF treatment can have any effect on the mechanical causes of DME. In eyes in which retinal edema and thickening seem out of proportion to clinical and OCT findings of traction, a trial of multiple intravitreal pharmacological treatments should be considered prior to surgery.

However, in addition to the surgical risks of vitrectomy, the increased clearance of anti-VEGF and other pharmacological agents in a vitrectomized eye should be considered. Grading and quantifying clinically significant vs insignificant abnormal vitreomacular adhesions on OCT have yet to be performed. We hope that with more imaging studies and OCT surgical correlations, we will be better able to predict which eyes with DME are best treated with surgery and, in the future, even pharmacologic vitreolysis. Retinal Physician delivers in-depth coverage of the latest advances in AMD, diabetic retinopathy, macular edema, retinal vein occlusion as well as surgical intervention in posterior segment care. Most cases of cystoid macular edema develop when blood vessels in the retina begin leak fluid.
For patients who have had cataract surgery, cystoid macular edema usually occurs about two to eight weeks after surgery. After symptoms of cystoid macular edema are present, your doctor may perform a series of diagnostic tests to confirm diagnosis. While this disease can be detected by your doctor before symptoms are present, it is usually very difficult to detect.
Treatment for cystoid macular edema will vary depending on the severity and cause of the condition and the individual patient. Most patients experience significant improvements to their vision after one or more of these treatment options, with full recovery taking several months.
Swelling of the central macular region of the retina can reduce the visual acuity (sharpness of vision).
Macular edema can be detected with ophthalmic biomicroscopy ophthalmic computerized tomography (OCT) and fluorescein angiography.
Cataract surgery can be performed with this condition, however, patient education and specific treatments and techniques may come into play to make sure everything goes smoothly. In addition, the decision of whether to implant a multifocal IOL and how this could affect future treatments and progression of macular disease comes into play. Choudhry uses NSAIDs postoperatively after all phaco for pain and inflammation and to prevent CME. He said in these cases, he would have a patient use NSAIDs both preoperatively and postoperatively. Miller believes it's a bad idea for patients with macular disease to receive multifocal IOL implantations, but there are some exceptions. Miller said operating through a multifocal IOL is doable, but retina specialists would probably prefer a clean view. PhysiciansJobsPlus allows you to post your resume, receive relevant ophthalmology open position alerts via email and apply for positions online.
We also outline a proposed classification scheme for vitreoretinal interface abnormalities in patients with DME, along with illustrative cases. This is useful given the challenges in reviewing this topic as a result of heterogeneous study populations and the mix of pre-OCT and post-OCT reports in the literature.
One theory is that the primary insult of hyperglycemia leads to the development and acceleration of advanced glycation end products (AGEs). Decreasing their halflife early on in the course of a patient’s treatment could necessitate more frequent injections to maintain VEGF blockade or require medication via sustained-release devices. Evaluation of the vitreomacular interface is best accomplished by funduscopic examination and OCT imaging. Surgery includes vitrectomy with detachment of the posterior hyaloid, if present, and peeling of any associated epiretinal membranes, with or without internal limiting membrane removal.
The first category we have termed DME with abnormal vitreomacular adhesions or proliferation, or both. Fundus photo (top) of a patient with chronic DME unresponsive to intravitreal bevacizumab and triamcinolone. The earliest stage of PVD is a separation of the perifoveal hyaloid from the ILM, with persistent adherence to the fovea itself. Fundus photo (top) of a patient with DME and clinically visible partial posterior hyaloid detachment with broad based macular traction. Fundus photos and OCTs of a monocular patient with a history of PDR and panretinal photocoagulation. This clarification would be helpful in determining how to apply the older literature on taut hyaloids in patients in currentday practice. Clinically, vitreomacular traction and vitreofoveal traction produce greater distortion to the retinal surface and have a noticeable elevation to the posterior hyaloid, as opposed to a taut hyaloid, in which the elevation of the hyaloid is clinically difficult to discern from the surface of the retina.
This greater hyaloid separation in VMT and VFT also results in a greater angle of incidence between the hyaloid and retinal surface. Fundus photo (top) of a patient with partially opaque vascularized preretinal membrane with DME and proliferative retinopathy. They can become thickened and vascularized if neovascularization grows within the membrane.
The authors suggested that the improvement in visual acuity might have resulted from improvement in visual distortion rather than DME.
Because the ILM is a sheet of basement membrane without elasticity, it is capable of transmitting tangential traction onto the retina with distant effects.
Macular ILM peeling could be indicated in cases of persistent diffuse DME in which the ILM is taut.
In addition to removal of the posterior hyaloid, removal of the ILM has been advocated by some authors. The rationale for surgical treatment was that it released tractionalmediated effects of the hyaloid and ILM and allowed for clearance of a permeability barrier.
Unfortunately, we still have no fail-safe way of determining which eyes will benefit from vitrectomy and which will not. Red-free photograph (top) of a patient with new-onset DME three years after pars plana vitrectomy and posterior hyaloid removal.
TAUT INTERNAL LIMITING MEMBRANE CAUSING DIFFUSE DIABETIC MACULAR EDEMA AFTER VITRECTOMY: CLINICOPATHOLOGICAL CORRELATION. The diagnosis of tractional causes of DME can most often be made clinically and confirmed by OCT findings. Theoretically, ILM removal can ensure complete removal of the cortical vitreous and other tractional elements.
Even though OCT does not clearly image a mechanical cause of this entity, its etiology is believed to be caused by tangential traction across the ILM by contractile cellular elements.
The authors suspect that both tractional (mechanical) and nontractional (biochemical) factors play roles in some eyes with DME. If patients do not respond to medical therapy, and there seems to be preoperative evidence suggesting a tractional component to DME, pars plana vitrectomy can be considered. OCT findings of traction should always be correlated with clinical findings, because abnormal vitreomacular adhesions are not uncommon and may, in some cases, not be the primary cause of DME. We believe our classification scheme is a step toward a better understanding of the vitreoretinal interface in DME.

It reaches both retinal specialists and general ophthalmologists with practical insight regarding current and future treatment strategies in medical and surgical retina care. The macula is responsible for the detailed, central vision that provides the ability to see objects with great detail.
Vision may also be distorted, with straight lines appearing wavy, and may be tinted pink as well.
He has been using them since the mid 1990s, and he said NSAIDs are often the path of choice, unless there is a specific contraindication to using them. Choudhry said, therefore this would mean he or she is not a good candidate for a multifocal IOL.
This category is separated into three different entities, based on differences in clinical appearance and OCT findings. This overlap has made the classification of these disease processes confusing in the literature. These eyes were observed to have a thickened and taut premacular posterior hyaloid.14 OCT was not available at the time of the original publication, and the funduscopic features included a glistening sheen and striae to the posterior hyaloid (Figure 1). They had visual acuity improvement in four out of 10 patients following vitrectomy for DME with a taut hyaloid.
It was initially described with the help of B-scan ultrasonography in eyes without diabetic retinopathy, which had the hyaloid detached peripherally but still adherent to the macula. These eyes underwent pars plana vitrectomy with ERM or ILM peeling performed at the surgeon’s discretion. 21 Differentiating between a taut hyaloid and vitreomacula or vitreofoveal traction, or both, may not be clinically significant because each may represent different presentations of a similar phenomenon, only differentiated by the degree of separation of the hyaloid and angle of vitreoretinal traction.
OCT shows a hyper-reflective membrane that may distort the normal contour of the inner retina. The membranes form in response to the growth and regression of preretinal neovascularization into the posterior hyaloid.
When the subgroup of 87 patients with vitreomacular traction was excluded, 94 (61%) of the additional 154 had ERM peeling, which was associated with improved visual acuity. Not unique to this study, this disconnect appears to be due to the lack of correlation between visual acuity and macular thickness. Even though others have had similar results, most studies have yielded variable visual results not as good as the anatomical results. National Diabetes Fact Sheet: National Estimates and General Information on Diabetes and Prediabetes in the United States. Association between the short-term natural history of diabetic macular edema and the vitreomacular relationship in type II diabetes mellitus. Difference in clearance of intravitreal triamcinolone acetonide between vitrectomized and nonvitrectomized eyes. Epiretinal pathology of diffuse diabetic macular edema associated with vitreomacular traction. Vitrectomy for diabetic macular traction and edema associated with posterior hyaloidal traction. Vitrectomy for diffuse diabetic macular edema associated with a taut premacular posterior hyaloid. Vitrectomy for diabetic macular edema associated with a thickeΪned and taut posterior hyaloid membrane.
Macular traction detachment and diabetic macular edema associated with posterior hyaloidal traction. Optical coherence tomography for evaluating diabetic macular edema before and after vitrectomy.
Pathology of epiretinal membrane, idiopathic macular hole, and vitreomacular traction syndrome.
Taut internal limiting membrane causing diffuse diabetic macular edema after vitrectomy: Clinicopathological correlation. Frequency and associations of a taut thickened posterior hyaloid, partial vitreomacular separation, and subretinal fluid in patients with diabetic macular edema. Resolution of diabetic macular edema after surgical removal of the posterior hyaloid and the inner limiting membrane. A randomised controlled feasibility trial of vitrectomy versus laser for diabetic macular oedema. Comparative evaluation of vitrectomy and dye-enhanced ILM peel with grid laser in diffuse diabetic macular edema.
Factors predicting outcome of vitrectomy for diabetic macular oedema: Results of a prospective study. The most comprehensive retinal care journal, Retinal Physician puts into perspective what the scientific developments mean to today’s practice and discusses ramifications of new studies, treatments and patient management strategies.
Miller has patients use an NSAID for three to four weeks after surgery, making a reassessment around four weeks. People with conditions like diabetes or vein occlusions should generally not receive multifocal IOLs, but he said if someone had a couple of drusen, this would not necessarily be a reason to not put in a multifocal IOL.
Gentile, MD, FACS, is professor of ophthalmology at the New York Eye and Ear Infirmary, New York Medical College (Valhalla, NY) and attending surgeon at Winthrop University Hospital (Mineola, NY). In addition to promoting leukostasis and causing damage to both pericytes and endothelial cells, AGEs are believed to promote mechanical changes in the vitreous and at the vitreous-retinal interface. The striae were limited to the hyaloid and did not involve the retina or associated retinal vessels, differentiating it from eyes with ERMs. OCT (inset) revealed a partial hyaloid detachment with asymmetric hyaloid separation and multiple vitreomacular adhesions around the fovea with underlying retinal edema. Fundus photo (above) and OCT (inset) revealed a partial hyaloid detachment with a focal vitreofoveal adhesion and underlying retinal edema. The DME was unresponsive to focal laser, intravitreal bevacizumab, and intravitreal triamcinolone. Rosenthal said using an NSAID at least preoperatively, and often postoperatively, is very common today.
There will always be hard exclusions, cases where there are no issues with putting in a multifocal IOL, and cases where a doctor has to exercise his or her judgment. The corresponding OCT (inset) revealed a low-lying partial hyaloid detachment with multiple vitreomacular adhesions over the fovea with underlying retinal edema. Because of this, there has not yet been adequate correlation between the ophthalmoscopic and OCT findings of these subtypes.
Postoperative OCT (bottom) two weeks after ILM peeling revealed resolution of the DME and restoration of a normal foveal contour. During pars plana vitrectomy, the membranes were found to be extremely adherent, and membrane peeling was limited to the macular area.

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