Outcomes for Successfully Repaired Macula-Off Diabetic Tractional Retinal Detachment

Abstract

Purpose: To report the anatomic and functional outcomes in diabetic macula-off tractional retinal detachment. Design: Multicenter, retrospective, interventional, consecutive case series. Participants: 30 selected eyes of 26 patients (out of 256 eyes of 124 consecutive patients) with a mean diabetes evolution period of 18.4 ± 4.8 years SD who underwent successful vitrectomy techniques for tractional retinal detachment involving the macula, between January 2016 and December 2020. Methods: All patients underwent pars plana vitrectomy and successfully surgical resolution of tractional retinal detachment forming only one surgery group and more than one surgery group in cases of recurrent diabetic TRD. Structural, perfused and functional postoperative findings were statistical analized. Main outcome measures: The primary outcomes were to analized the perfusional, structural and functional postoperative findings of the intentionally selected eyes with a fully resolved diabetic TRD that underwent timely sophisticated pars plana vitrectomy (PPV) techniques. The secondary outcomes were correlating the longterm final postoperative BCVA with the multimodal, serial postoperative multimodal evaluation. Results: The mean difference between the pre-, 3 months and final postoperative BCVA was significant (p < 0.05). The mean duration of vision loss before surgery was 11.6 ± 2.3 weeks SD. The mean time for macular detachment resolution was 3.6 ± 1.7 weeks in the group showing pure macular tractional detachment and 1.8 ± 0.8 weeks in the group showing combined tractional and rhegmatogenous macular detachment (p < 0.05) for the eye group with one surgery only and 12.2 ± 8.1 weeks SD for the eyes with more than one surgery (p < 0.05). Mean follow-up 11.4 ± 5.7 months. Longitudinal multimodal imaging tests demonstrated abnormal superficial and deep microcirculation patterns with multiple micro-abnormalities of the foveal avascular zone and different but distinct areas of non-perfused macula on OCT angiography, as well as the presence of disorganization of the retinal inner layers (DRIL) and chronic ischemic macular edema in 82% of the eyes examined by SD-OCT. Microperimetry, chromatic macular visual field testing and mfERG testing revealed an abnormal retinal response with an unstable eccentric foveocentral fixation pattern and a profound reduction in the N1and P1-wave nV amplitudes with a prolonged P1 implicit time. Conclusion: Despite successful anatomical reattachment of the macula, long-term postoperative microcirculatory abnormalities along with persistent and ischemic tissue were detected predominantly in the recurrent TRD group due to multiple microcirculatory defects, including ischemic edema of the external and internal layers of the retina and DRIL. *Corresponding author: Miguel A Quiroz-Reyes, MD, Institute of Ophthalmology, Fundacion Conde de Valenciana, Private Assistance Institution (IAP) Nonprofit Organization, Chimalpopoca 14 Street, Colonia Obrera, Mexico City 06800, Mexico; Oftalmologia Integral ABC and Retina Specialists SC at the American British Cowdray Hospital, Private Assistance Institution (Nonprofit Organization), Av. Carlos Graef Fernandez 154, Cuajimalpa de Morelos, Mexico City 05300, Mexico, Tel: +525-55-5442-1700, Fax: +525-55-1664-7180 Check for updates ISSN: 2378-346X DOI: 10.23937/2378-346X/1410131 Quiroz-Reyes et al. Int J Ophthalmol Clin Res 2021, 8:131 • Page 2 of 18 • Background Diabetes Mellitus (DM) is a worldwide problem specially in developing countries due to poor medical care. Among the main causes of potentially treated severe visual loss are diabetic macular edema (DME) and chronic cystic macular edema (CME) and complications related to proliferative diabetic retinopathy (PDR) such as recurrent vitreous hemorrhages (VH), tractional retinal detachment (TRD), refractory macular edema associated with posterior hyaloid traction, combined traction/rhegmatogenous retinal detachment and epiretinal membrane /ERM) proliferation are the most common indications of surgical vitrectomy [1-3]. Anti-VEGF is a very useful method in the management of diabetic retinopathy (DR). In selected patients the applications of adjuvants as steroids in paraocular injections or by intravitreous extended-release devices have gained popularity for their practicality effectiveness in maintaining long-term vision. It has left the panretinal photocoagulation (PRP) as a second-line treatment in developed countries [4]. The results of the Diabetic Retinopathy Clinical Research Network Protocol and the CLARITY (clinical efficacy and mechanistic evaluation of aflibercept for proliferative diabetic retinopathy) trials has been used as guidelines for the surveillance and management of patients with macular edema and complications related to proliferative diabetic retinopathy [4]. These results are found to be better over classical PRP treatment. In case of delayed detection of diabetic retinopathy, it must be treated by advanced pars plana vitrectomy (PPV) techniques. The visual outcomes after diabetic vitrectomy, however, have not undergone a similar change [5,6]. In spite of numerous studies the predictive factors of visual outcomes remain to be elucidated [7]. Sun, et al. [8] have used the horizontal B-scan of optical coherence tomography (OCT) images to characterize the disorganization of the retinal inner layers (DRIL) as the inability to distinguish any of the boundaries of the ganglion cell layer-inner plexiform layer (GCL-IPL) complex, inner nuclear layer (INL), and outer plexiform layer (OPL). Regarding DME, DRIL was reported to be associated with poor BCVA and changes in the DRIL affects the subsequent changes in final BCVA. OCTA is a noninvasive OCT platform to create in vivo 3-dimensional composites of separate layers of the retinal and choroidal vasculature without the use of a contrast agent [9]. Sensitivity can be increased through multiple algorithms for detailed imaging of each superficial and deep retinal capillary plexus as well as the choriocapillaris [10-12]. The OCTA images can be automatically segmented to provide an en face, depthencoded region of the vasculature that is co-registered with the structural OCT B-scan. OCTA eliminates the need for a dye [13,14], and eliminates the “transit window” seen with both fluorescein angiography (FA) and indocyanine (ICG). OCTA also avoids the dark artifact of retinal and vascular features that may occur with dye leakage [15]. The capillary-level detail with high depth resolution provides information given only by histological studies [16-20]. In patients with DR, OCTA demonstrates retinal foveal avascular zone (FAZ) enlargement, and microaneurysms. The ability to separately examine the superficial and deep capillary plexuses with OCTA helps users delineate retinal involvement in various diabetic lesions. AngioVue imaging showing superficial and deep plexuses with vessel density quantification of proliferative DR shows areas of nonperfusion, microaneurysms, and clear enlargement of the FAZ [21]. Studies show that FA cannot resolve the deep capillary plexus or peripapillary radial capillaries at all [15,16,22]. Most, if not all, of the clinically relevant macular findings are demonstrable and correlated with OCTA findings in DR [23,24]. OCTA is a superior tool for quantitatively evaluating the severity of non-perfused retina. OCTA can reliably detect both neovascularization of the disc (NVD) and elsewhere (NVE), assuming that the pathology is within the field of view [25-27]. These advancements are expected to improve the management