The Changing (Hyaloid) Face of Diabetic Maculapathy –
a 25 Gauge Perspective
William V. Aldred (Pensacola)
Demographic and lifestyle
changes in the western world have not only caused a major increase in
the incidence of diabetes mellitus, but have driven changes in the spectrum
of the disease over time. Possibly because of more advanced medical therapies,
paradoxical trends, such as “better” glucose control despite
the presence of greater obesity, have been noted. Such emerging metabolic
patterns may be influencing the manifold complications of this disease,
including retinopathy.
Correspondingly, many vitreoretinal surgeons are noting and (at least
informally) discussing changes in the profile of their diabetic practices.
From the ophthalmologic standpoint, the salient development is a shift
toward even greater emphasis upon recognition and treatment of certain
pathologic vitreoretinal and vitreomacular anatomic relationships. Optical
Coherence Tomography has greatly facilitated the awareness of subtle tractional
lesions and tenuous epiretinal membranes. The contribution of these lesions
to chronic edema and macular dysfunction is increasingly appreciated..
Over the years, vitreous surgeons have developed an understanding that
separation of various adhesions and membranes from the peripheral retina,
and especially from the macula, may represent the “cornerstone”
of success in treating diabetic retinopathy. Because of the above technological
advances, and therapeutic changes, this trend “away” from
laser and “toward” release or removal of surface abnormalities
has accelerated. The relatively disappointing results with laser photocoagulation
of diffuse diabetic macular edema, and the greater perceived benefit of
“modern vitrectomy” for this condition, exemplifies this evolving
therapeutic philosophy. A twenty five gauge vitrectomy approach is uniquely
suited to address this changing “face” of diabetic retinopathy.
The small size of the vitrector port, flow characteristics, and available
ancillary instruments combine to yield a margin of precision and safety
better than was available in the past. Ease of combination with phacoemulsification/IOL
implantation is also an advantage of the 25 g technique in select cases.
In addition, the improved ocular surface characteristics in the early
postoperative period consequent to less “invasive” incisions
facilitate healing and minimize
early anterior segment complications. The learning curve for more complex
25g diabetic cases is steeper, however. I will review these issues from
the perspective of a community retinal practice that has embraced 25g
vitrectomy from its inception.
Practical advice for the surgeon transitioning to this technology will
be given, with generous video accompaniment.