Clinical observation of pars plana vitrectomy combined with subretinal injection of dexamethasone for the treatment of refractory diabetic macular edema_Chinese Journal of Ocular Fundus Diseases

Authors：

Zhang Hui , Wang Ying ,  Han Quanhong

Tianjin Eye Hospital, Tianjin Key Laboratory of Ophthalmology and Visual Science, Tianjin Eye Institute, Nankai University Affiliated Eye Hospital, Clinical College of Ophthalmology of Tianjin Medical University, Tianjin 300384, China;

Corresponding author：

Han Quanhong, Email: hanquanhong126@126.com

Keywords：

Refractory diabetic macular edema; Pars plana vitrectomy; Subretinal injection; Dexamethasone

DOI：

10.3760/cma.j.cn511434-20240715-00262

Video：

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Objective To observe the effectiveness and safety of subretinal dexamethasone injection in treating refractory diabetic macular edema (DME). Methods A prospective case study. From January 2024 to March 2024, 9 refractory DME patients with 10 eyes diagnosed in Tianjin Eye Hospital were included. All eyes had a central macular thickness (CMT) of more than 275 μm despite undergoing anti-vascular endothelial growth factor therapy at least 5 times. 25G pars plana vitrectomy was performed for the patients combined with internal limiting membrane peeling and subretinal injection of dexamethasone sodium phosphate. Patients underwent ophthalmic evaluation, including best-corrected visual acuity (BCVA), microperimetry and optical coherence tomography testing before surgery and 1 month and 3 months postoperatively. The international standard visual acuity chart was used for BCVA examination, which was statistically converted into logMAR visual acuity. The BCVA, the mean sensitivity (MS) and the CMT before and after surgery were compared using paired t test. The intraoperative and postoperative complications were recorded. Results Nine cases had 10 eyes, 4 males had 5 eyes and 5 females had 5 eyes. Age 43-79 (65.3±10.8) years old. logMAR BCVA was 0.84±0.25, 0.72±0.31 and 0.63±0.22 before and 1 and 3 months after surgery, respectively. MS was (16.48±5.03), (16.6±6.31), (18.0±5.33) dB, respectively. CMT was (437.5±90.4), (306.9±87.4), (288.7±87.3) μm, respectively. Compared with before surgery, BCVA: 1 month after surgery had no statistically significant difference (t=2.025, P=0.074), 3 months after surgery had statistically significant difference (t=5.161, P=0.001); MS: 1 and 3 months after surgery, there was no significant difference (t=－0.078, －1.022; P=0.940, 0.334); CMT: the difference was statistically significant 1 and 3 months after surgery (t=2.892, 3.175; P=0.018, 0.011), and the difference was statistically significant 1 and 3 months after surgery (t=2.427, P=0.038). There were no complications such as macular hiatus, vitreous hematoma and retinal detachment during and after surgery in all patients. During the follow-up period, there was no increase in intraocular pressure and cataract. Conclusion The combined treatment strategy involved pars plana vitrectomy, internal limiting membrane peeling and subretinal injection of dexamethasone can effectively reduce CMT in refractory DME patients, improve visual acuity and have good safety.

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5.	Morizane Y, Kimura S, Hosokawa M, et al. Planned foveal detachment technique for the resolution of diffuse diabetic macular edema[J]. Jpn J Ophthalmol, 2015, 59(5): 279-287. DOI: 10.1007/s10384-015-0390-4.
6.	Toshima S, Morizane Y, Kimura S, et al. Planned foveal detachment technique for the resolution of diabetic macular edema resistant to anti-vascular endothelial growth factor therapy[J]. Retina, 2019, 39(Suppl 1): S162-S168. DOI: 10.1097/IAE.0000000000001771.
7.	El-Baha SM, Abdel Hadi AM, Abouhussein MA. Submacular injection of Ranibizumab as a new surgical treatment for refractory diabetic macular edema[J/OL]. J Ophthalmol, 2019(4): 6274209[2019-10-21]. https://pubmed.ncbi.nlm.nih.gov/31772766/. DOI: 10.1155/2019/6274209.
8.	Romero-Aroca P, Baget-Bernaldiz M, Pareja-Rios A, et al. Diabetic macular edema pathophysiology: vasogenic versus inflammatory[J/OL]. J Diabetes Res, 2016: 2156273[2013-09 -28]. https://pubmed.ncbi.nlm.nih.gov/27761468/. DOI: 10.1155/2016/2156273.
9.	Elman MJ, Bressler NM, Qin H, et al. Expanded 2-year follow-up of ranibizumab plus prompt or deferred laser or triamcinolone plus prompt laser for diabetic macular edema[J]. Ophthalmology, 2011, 118(4): 609-614. DOI: 10.1016/j.ophtha.2010.12.033.
10.	Song SJ, Sohn JH, Park KH. Evaluation of the efficacy of vitrectomy for persistent diabetic macular edema and associated factors predicting outcome[J]. Korean J Ophthalmol, 2007, 21(3): 146-150. DOI: 10.3341/kjo.2007.21.3.146.
11.	Boyer DS, Yoon YH, Belfort R, et al. Three-year, randomized, sham-controlled trial of dexamethasone intravitreal implant in patients with diabetic macular edema[J]. Ophthalmology, 2014, 121(10): 1904-1914. DOI: 10.1016/j.ophtha.2014.04.024.
12.	惠延年, 梁厚成, 胡丹, 等. 玻璃体手术与地塞米松眼内灌注治疗增殖性玻璃体视网膜病变[J]. 第四军医大学学报, 1996, 17(5): 387-388.Hui YN, Liang HC, Hu D, et al. Hyaline surgery and intraocular dexamethasone infusion in the treatment of proliferative vitreoretinopathy[J]. J Fourth Mil Med Univ, 1996, 17(5): 387-388.

1. Romero-Aroca P, de la Riva-Fernandez S, Valls-Mateu A, et al. Changes observed in diabetic retinopathy: eight-year follow-up of a Spanish population[J]. Br J Ophthalmol, 2016, 100(10): 1366-1371. DOI: 10.1136/bjophthalmol-2015-307689.
2. Schmidt-Erfurth U, Garcia-Arumi J, Bandello F, et al. Guidelines for the management of diabetic macular edema by the European Society of Retina Specialists (EURETINA)[J]. Ophthalmologica, 2017, 237(4): 185-222. DOI: 10.1159/000458539.
3. Flaxel CJ, Adelman RA, Bailey ST, et al. Diabetic retinopathy preferred practice pattern®[J]. Ophthalmology, 2020, 127(1): 66-145. DOI: 10.1016/j.ophtha.2019.09.025.
4. Diabetic Retinopathy Clinical Research Network, Wells JA, Glassman AR, et al. Aflibercept, Bevacizumab, or Ranibizumab for diabetic macular edema[J]. N Engl J Med, 2015, 372(13): 1193-1203. DOI: 10.1056/NEJMoa1414264.
5. Morizane Y, Kimura S, Hosokawa M, et al. Planned foveal detachment technique for the resolution of diffuse diabetic macular edema[J]. Jpn J Ophthalmol, 2015, 59(5): 279-287. DOI: 10.1007/s10384-015-0390-4.
6. Toshima S, Morizane Y, Kimura S, et al. Planned foveal detachment technique for the resolution of diabetic macular edema resistant to anti-vascular endothelial growth factor therapy[J]. Retina, 2019, 39(Suppl 1): S162-S168. DOI: 10.1097/IAE.0000000000001771.
7. El-Baha SM, Abdel Hadi AM, Abouhussein MA. Submacular injection of Ranibizumab as a new surgical treatment for refractory diabetic macular edema[J/OL]. J Ophthalmol, 2019(4): 6274209[2019-10-21]. https://pubmed.ncbi.nlm.nih.gov/31772766/. DOI: 10.1155/2019/6274209.
8. Romero-Aroca P, Baget-Bernaldiz M, Pareja-Rios A, et al. Diabetic macular edema pathophysiology: vasogenic versus inflammatory[J/OL]. J Diabetes Res, 2016: 2156273[2013-09 -28]. https://pubmed.ncbi.nlm.nih.gov/27761468/. DOI: 10.1155/2016/2156273.
9. Elman MJ, Bressler NM, Qin H, et al. Expanded 2-year follow-up of ranibizumab plus prompt or deferred laser or triamcinolone plus prompt laser for diabetic macular edema[J]. Ophthalmology, 2011, 118(4): 609-614. DOI: 10.1016/j.ophtha.2010.12.033.
10. Song SJ, Sohn JH, Park KH. Evaluation of the efficacy of vitrectomy for persistent diabetic macular edema and associated factors predicting outcome[J]. Korean J Ophthalmol, 2007, 21(3): 146-150. DOI: 10.3341/kjo.2007.21.3.146.
11. Boyer DS, Yoon YH, Belfort R, et al. Three-year, randomized, sham-controlled trial of dexamethasone intravitreal implant in patients with diabetic macular edema[J]. Ophthalmology, 2014, 121(10): 1904-1914. DOI: 10.1016/j.ophtha.2014.04.024.
12. 惠延年, 梁厚成, 胡丹, 等. 玻璃体手术与地塞米松眼内灌注治疗增殖性玻璃体视网膜病变[J]. 第四军医大学学报, 1996, 17(5): 387-388.Hui YN, Liang HC, Hu D, et al. Hyaline surgery and intraocular dexamethasone infusion in the treatment of proliferative vitreoretinopathy[J]. J Fourth Mil Med Univ, 1996, 17(5): 387-388.

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