Gastaud P, Schauer Ph, Rouhette H, Folquet P, Negre F
Service d'ophtalmologie, Hôpital Saint Roch, 5 rue P. Devoluy, 06000 Nice, France.
J Fr Ophtalmol. 2002 Feb;25(2):166-77.
The place of surgery in the treatment of diabetic macular edema is still not clearly defined even though the functional benefits of photocoagulation are less than satisfactory. Key words: Diabetic maculopathy, vitrectomy, internal limitant layer, serous detachment, hard exsudates.
We conducted a retrospective study on 40 consecutive cases of diabetic patients, each suffering from serious diabetic maculopathy and for whom photocoagulation would be either impossible to carry out or ineffective. Eighty percent of this study sample exhibited solid vitreomacular adhesions at vitrectomy. The internal limitant layer was dissected systematically. In all cases, plugging by perfluorocarbon liquids during the operation helped posterior focal endophotocoagulation. A gas tamponade was used in all cases. In 18 cases, surgical extraction of large intra- and/or subretinal clumps of hard exudates was necessary to replace the posterior pole.
The anatomical results were satisfactory in 97.5% of cases. The functional results were good but their interpretation is more difficult: the visual gain varied as a function of the clinical preoperative condition and how recent the condition was. The best results were obtained in edema with tractional predominance. The smallest visual gains were observed in cases of massive macular hard exudates. The most serious complication was a retinal detachment secondary to a parapapillary nasal retinal break occurring at a distance from the operation during a postoperative photocoagulation complement.
Vitrectomy released both tangential and axial tractional forces found in diabetic macular edema pathogenesis. The extraction of large clumps of exudates allowed us to replace serous retinal detachments and the photocoagulation of capillary anomalies. In addition, removing premacular vitreous body and gaseous plugging seemed to osmotically resorb the posterior pole edema. These surgical results have made us considerably reduce the use of photocoagulation for diffuse diabetic macular edema in the past four years.
