Macular morphology and vascular parameters changes following micro-invasive vitrectomy in patients with severe non-proliferative diabetic retinopathy_Chinese Journal of Ocular Fundus Diseases

Authors：

Zheng Wenbin , Lin Ying , Lai Kunbei , Chen Shida , Ding Xiaohu , Liu Bingqian , Xiao Sainan , Li Jizhu , Ma Yuan , Chen Ziye , Liang Xiaoling , Lyu Lin ,  Li Tao

State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou 510060, China;

Corresponding author：

Li Tao, Email: litao2@mail.sysu.edu.cn

Keywords：

Diabetic retinopathy; Surgical procedures, minimally invasive; Vitrectomy; Regional blood flow

DOI：

10.3760/cma.j.cn511434-20211207-00686

Video：

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Objective To observe the changes of macular morphology and blood flow after minimally invasive vitrectomy (PPV) in patients with severe non-proliferative diabetic retinopathy (sNPDR). Methods A prospective clinical study. From January 2020 to April 2021, 17 consecutive sNPDR patients with 17 eyes who were diagnosed and received PPV treatment at the Zhongshan Ophthalmic Center of Sun Yat-sen University were included in the study. There were 12 males with 12 eyes and 5 females with 5 eyes; the average age was 55 years old; the average duration of diabetes was 11 years; the average glycosylated hemoglobin was 7.9%. Before the operation and 1, 3, and 6 months after the operation, all the affected eyes underwent best corrected visual acuity (BCVA), standard 7-field fundus color photography, and optical coherence tomography angiography (OCTA). An OCTA instrument was used to scan the macular area of the affected eye with in the range of 3 mm×3 mm to measure the central subfoveal thickness (CST), the thickness of the ganglion cell complex (GCC) in the macular area, the thickness of the retinal nerve fiber layer (RNFL), and the superficial capillary plexus (SCP) vessel density and perfusion density in the macular area, macular avascular zone (FAZ) area, a-circularity index (AI). Before the operation and 6 months after the operation, the least significant difference test was used for the pairwise comparison. Results Before the operation, 1, 3, and 6 months after the operation, the FAZ area of the macular area were 0.34±0.14, 0.35±0.10, 0.37±0.10, 0.36±0.13 mm², respectively; AI were 0.52±0.13, 0.54±0.11, 0.57±0.10, 0.60±0.11; CST was 282.6±66.7, 290.4±70.9, 287.2±67.5, 273.2±49.6 μm; GCC thickness were 77.1±15.5, 74.3±13.9, 72.6±16.2, 78.5±18.3 μm; the thickness of RNFL was 97.9±13.8, 101.3±14.6, 97.7±12.0, 96.1±11.4 μm, respectively. The overall blood flow density of SCP in the macula were (16.79±1.43)%, (16.71±1.82)%, (17.30±2.25)%, (17.35±1.22)%; the overall perfusion density were 0.32±0.02, 0.32±0.03, 0.33±0.03, 0.33±0.02, respectively. After the operation, the CST increased first and then decreased; the thickness of RNFL increased 1 month after the operation, and then gradually decreased. Comparison of the parameters before and 6 months after the operation showed that the AI improved, and the difference was statistically significant (P=0.049); the difference in FAZ area and the thickness of CST, GCC, and RNFL was not statistically significant (P=0.600, 0.694, 0.802, 0.712); There was no statistically significant difference in the retina SCP blood flow density and perfusion density in the macular area (P=0.347, 0.361). Conclusion Compared with before surgery, there is no significant change in macular structure and blood flow density in sNPDR patients within 6 months after minimally invasive PPV.

Citation： Zheng Wenbin, Lin Ying, Lai Kunbei, Chen Shida, Ding Xiaohu, Liu Bingqian, Xiao Sainan, Li Jizhu, Ma Yuan, Chen Ziye, Liang Xiaoling, Lyu Lin, Li Tao. Macular morphology and vascular parameters changes following micro-invasive vitrectomy in patients with severe non-proliferative diabetic retinopathy. Chinese Journal of Ocular Fundus Diseases, 2022, 38(1): 34-39. doi: 10.3760/cma.j.cn511434-20211207-00686 Copy

1.	Flynn HW Jr, Chew EY, Simons BD, et al. Pars plana vitrectomy in the early treatment diabetic retinopathy study. ETDRS report number 17. The Early Treatment Diabetic Retinopathy Study Research Group[J]. Ophthalmology, 1992, 99(9): 1351-1357. DOI: 10.1016/s0161-6420(92)31779-8.
2.	Flaxel CJ, Adelman RA, Bailey ST, et al. Diabetic retinopathy preferred practice pattern®[J]. Ophthalmology, 2020, 127(1): P66-P145. DOI: 10.1016/j.ophtha.2019.09.025.
3.	Zheng W, Chen S, Ding X, et al. Microinvasive pars plana vitrectomy versus panretinal photocoagulation in the treatment of severe non-proliferative diabetic retinopathy (the VIP study): study protocol for a randomised controlled trial[J/OL]. BMJ Open, 2021, 11(2): e43371[2021-02-22]. https://pubmed.ncbi.nlm.nih.gov/33619191/. DOI: 10.1136/bmjopen-2020-043371.
4.	Alagorie AR, Nittala MG, Velaga S, et al. Association of intravitreal aflibercept with optical coherence tomography angiography vessel density in patients with proliferative diabetic retinopathy: a secondary analysis of a randomized clinical trial[J]. JAMA Ophthalmol, 2020, 138(8): 851-857. DOI: 10.1001/jamaophthalmol.2020.2130.
5.	Lorusso M, Milano V, Nikolopoulou E, et al. Panretinal photocoagulation does not change macular perfusion in eyes with proliferative diabetic retinopathy[J]. Ophthalmic Surg Lasers Imaging Retina, 2019, 50(3): 174-178. DOI: 10.3928/23258160-20190301-07.
6.	American Diabetes Association. 2. Classification and diagnosis of diabetes: standards of medical care in diabetes-2019[J]. Diabetes Care, 2019, 42(Suppl 1): S13-28. DOI: 10.2337/dc19-S002.
7.	Wilkinson CP, Ferris FR, Klein RE, et al. Proposed international clinical diabetic retinopathy and diabetic macular edema disease severity scales[J]. Ophthalmology, 2003, 110(9): 1677-1682. DOI: 10.1016/S0161-6420(03)00475-5.
8.	Iyer SSR, Lagrew MK, Tillit SM, et al. The vitreous ecosystem in diabetic retinopathy: insight into the patho-mechanisms of disease[J/OL]. Int J Mol Sci, 2021, 22(13): 7142[2021-07-01]. https://pubmed.ncbi.nlm.nih.gov/34281192/. DOI: 10.3390/ijms22137142.
9.	Holekamp NM. The vitreous gel: more than meets the eye[J]. Am J Ophthalmol, 2010, 149(1): 32-36. DOI: 10.1016/j.ajo.2009.07.036.
10.	Barile GR, Pachydaki SI, Tari SR, et al. The RAGE axis in early diabetic retinopathy[J]. Invest Ophthalmol Vis Sci, 2005, 46(8): 2916-2924. DOI: 10.1167/iovs.04-1409.
11.	Ferris F. Early photocoagulation in patients with either type Ⅰ or type Ⅱ diabetes[J]. Trans Am Ophthalmol Soc, 1996, 94: 505-537.
12.	Fong DS, Girach A, Boney A. Visual side effects of successful scatter laser photocoagulation surgery for proliferative diabetic retinopathy: a literature review[J]. Retina, 2007, 27(7): 816-824. DOI: 10.1097/IAE.0b013e318042d32c.
13.	Writing Committee for the Diabetic Retinopathy Clinical Research Network, Gross JG, Glassman AR, et al. Panretinal photocoagulation vs intravitreous ranibizumab for proliferative diabetic retinopathy: a randomized clinical trial[J]. JAMA, 2015, 314(20): 2137-2146. DOI: 10.1001/jama.2015.15217.
14.	Obeid A, Su D, Patel SN, et al. Outcomes of eyes lost to follow-up with proliferative diabetic retinopathy that received panretinal photocoagulation versus intravitreal anti-vascular endothelial growth factor[J]. Ophthalmology, 2019, 126(3): 407-413. DOI: 10.1016/j.ophtha.2018.07.027.
15.	Iuliano L, Corbelli E, Bandello F, et al. Protective effect of vitrectomy on the course of diabetic retinopathy: a case report[J/OL]. Eur J Ophthalmol, 2020, 4: 1120672120968739[2020-11-04]. https://pubmed.ncbi.nlm.nih.gov/33148051/. DOI: 10.1177/1120672120968739.
16.	Šín M, Chrapek O, Karhanová M, et al. The effect of pars plana vitrectomy and nuclear cataract on oxygen saturation in retinal vessels, diabetic and non-diabetic patients compared[J]. Acta Ophthalmol, 2016, 94(1): 41-47. DOI: 10.1111/aos.12828.
17.	Spaide RF, Fujimoto JG, Waheed NK, et al. Optical coherence tomography angiography[J]. Prog Retin Eye Res, 2018, 64: 1-55. DOI: 10.1016/j.preteyeres.2017.11.003.
18.	AttaAllah HR, Mohamed A, Ali MA. Macular vessels density in diabetic retinopathy: quantitative assessment using optical coherence tomography angiography[J]. Int Ophthalmol, 2019, 39(8): 1845-1859. DOI: 10.1007/s10792-018-1013-0.
19.	Weisner G, Blindbaek SL, Tang FY, et al. Non-invasive structural and metabolic retinal markers of disease activity in non-proliferative diabetic retinopathy[J]. Acta Ophthalmol, 2021, 99(7): 790-796. DOI: 10.1111/aos.14761.
20.	Zhao H, Yu M, Zhou L, et al. Comparison of the effect of pan-retinal photocoagulation and intravitreal conbercept treatment on the change of retinal vessel density monitored by optical coherence tomography angiography in patients with proliferative diabetic retinopathy[J/OL]. J Clin Med, 2021, 10(19): 4484[2021-09-29]. https://pubmed.ncbi.nlm.nih.gov/34640502/. DOI: 10.3390/jcm10194484.
21.	Huang T, Li X, Xie J, et al. Long-term retinal neurovascular and choroidal changes after panretinal photocoagulation in diabetic retinopathy[J/OL]. Front Med (Lausanne), 2021, 8: 752538[2021-10-18]. https://pubmed.ncbi.nlm.nih.gov/34733867/. DOI: 10.3389/fmed.2021.752538.
22.	Takase N, Nozaki M, Kato A, et al. Enlargement of foveal avascular zone in diabetic eyes evaluated by en face optical coherence tomography angiography[J]. Retina, 2015, 35(11): 2377-2383. DOI: 10.1097/IAE.0000000000000849.
23.	Siegfried CJ, Shui YB. Intraocular oxygen and antioxidant status: new insights on the effect of vitrectomy and glaucoma pathogenesis[J]. Am J Ophthalmol, 2019, 203: 12-25. DOI: 10.1016/j.ajo.2019.02.008.
24.	Stefánsson E, Loftsson T. The stokes-einstein equation and the physiological effects of vitreous surgery[J]. Acta Ophthalmol Scand, 2006, 84(6): 718-719. DOI: 10.1111/j.1600-0420.2006.00778.x.
25.	Kim YM, Chung EJ, Byeon SH, et al. Pars plana vitrectomy with internal limiting membrane peeling compared with intravitreal triamcinolone injection in the treatment of diabetic macular edema[J]. Ophthalmologica, 2009, 223(1): 17-23. DOI: 10.1159/000161878.
26.	Fossataro F, Rispoli M, Pece A. OCTA in macular intraretinal microvascular abnormalities: Retinal vascular density remodeling after panretinal photocoagulation[J/OL]. Eur J Ophthalmol, 2021: 484559686[2021-11-09]. https://pubmed.ncbi.nlm.nih.gov/34751048/. DOI: 10.1177/11206721211059014.

1. Flynn HW Jr, Chew EY, Simons BD, et al. Pars plana vitrectomy in the early treatment diabetic retinopathy study. ETDRS report number 17. The Early Treatment Diabetic Retinopathy Study Research Group[J]. Ophthalmology, 1992, 99(9): 1351-1357. DOI: 10.1016/s0161-6420(92)31779-8.
2. Flaxel CJ, Adelman RA, Bailey ST, et al. Diabetic retinopathy preferred practice pattern®[J]. Ophthalmology, 2020, 127(1): P66-P145. DOI: 10.1016/j.ophtha.2019.09.025.
3. Zheng W, Chen S, Ding X, et al. Microinvasive pars plana vitrectomy versus panretinal photocoagulation in the treatment of severe non-proliferative diabetic retinopathy (the VIP study): study protocol for a randomised controlled trial[J/OL]. BMJ Open, 2021, 11(2): e43371[2021-02-22]. https://pubmed.ncbi.nlm.nih.gov/33619191/. DOI: 10.1136/bmjopen-2020-043371.
4. Alagorie AR, Nittala MG, Velaga S, et al. Association of intravitreal aflibercept with optical coherence tomography angiography vessel density in patients with proliferative diabetic retinopathy: a secondary analysis of a randomized clinical trial[J]. JAMA Ophthalmol, 2020, 138(8): 851-857. DOI: 10.1001/jamaophthalmol.2020.2130.
5. Lorusso M, Milano V, Nikolopoulou E, et al. Panretinal photocoagulation does not change macular perfusion in eyes with proliferative diabetic retinopathy[J]. Ophthalmic Surg Lasers Imaging Retina, 2019, 50(3): 174-178. DOI: 10.3928/23258160-20190301-07.
6. American Diabetes Association. 2. Classification and diagnosis of diabetes: standards of medical care in diabetes-2019[J]. Diabetes Care, 2019, 42(Suppl 1): S13-28. DOI: 10.2337/dc19-S002.
7. Wilkinson CP, Ferris FR, Klein RE, et al. Proposed international clinical diabetic retinopathy and diabetic macular edema disease severity scales[J]. Ophthalmology, 2003, 110(9): 1677-1682. DOI: 10.1016/S0161-6420(03)00475-5.
8. Iyer SSR, Lagrew MK, Tillit SM, et al. The vitreous ecosystem in diabetic retinopathy: insight into the patho-mechanisms of disease[J/OL]. Int J Mol Sci, 2021, 22(13): 7142[2021-07-01]. https://pubmed.ncbi.nlm.nih.gov/34281192/. DOI: 10.3390/ijms22137142.
9. Holekamp NM. The vitreous gel: more than meets the eye[J]. Am J Ophthalmol, 2010, 149(1): 32-36. DOI: 10.1016/j.ajo.2009.07.036.
10. Barile GR, Pachydaki SI, Tari SR, et al. The RAGE axis in early diabetic retinopathy[J]. Invest Ophthalmol Vis Sci, 2005, 46(8): 2916-2924. DOI: 10.1167/iovs.04-1409.
11. Ferris F. Early photocoagulation in patients with either type Ⅰ or type Ⅱ diabetes[J]. Trans Am Ophthalmol Soc, 1996, 94: 505-537.
12. Fong DS, Girach A, Boney A. Visual side effects of successful scatter laser photocoagulation surgery for proliferative diabetic retinopathy: a literature review[J]. Retina, 2007, 27(7): 816-824. DOI: 10.1097/IAE.0b013e318042d32c.
13. Writing Committee for the Diabetic Retinopathy Clinical Research Network, Gross JG, Glassman AR, et al. Panretinal photocoagulation vs intravitreous ranibizumab for proliferative diabetic retinopathy: a randomized clinical trial[J]. JAMA, 2015, 314(20): 2137-2146. DOI: 10.1001/jama.2015.15217.
14. Obeid A, Su D, Patel SN, et al. Outcomes of eyes lost to follow-up with proliferative diabetic retinopathy that received panretinal photocoagulation versus intravitreal anti-vascular endothelial growth factor[J]. Ophthalmology, 2019, 126(3): 407-413. DOI: 10.1016/j.ophtha.2018.07.027.
15. Iuliano L, Corbelli E, Bandello F, et al. Protective effect of vitrectomy on the course of diabetic retinopathy: a case report[J/OL]. Eur J Ophthalmol, 2020, 4: 1120672120968739[2020-11-04]. https://pubmed.ncbi.nlm.nih.gov/33148051/. DOI: 10.1177/1120672120968739.
16. Šín M, Chrapek O, Karhanová M, et al. The effect of pars plana vitrectomy and nuclear cataract on oxygen saturation in retinal vessels, diabetic and non-diabetic patients compared[J]. Acta Ophthalmol, 2016, 94(1): 41-47. DOI: 10.1111/aos.12828.
17. Spaide RF, Fujimoto JG, Waheed NK, et al. Optical coherence tomography angiography[J]. Prog Retin Eye Res, 2018, 64: 1-55. DOI: 10.1016/j.preteyeres.2017.11.003.
18. AttaAllah HR, Mohamed A, Ali MA. Macular vessels density in diabetic retinopathy: quantitative assessment using optical coherence tomography angiography[J]. Int Ophthalmol, 2019, 39(8): 1845-1859. DOI: 10.1007/s10792-018-1013-0.
19. Weisner G, Blindbaek SL, Tang FY, et al. Non-invasive structural and metabolic retinal markers of disease activity in non-proliferative diabetic retinopathy[J]. Acta Ophthalmol, 2021, 99(7): 790-796. DOI: 10.1111/aos.14761.
20. Zhao H, Yu M, Zhou L, et al. Comparison of the effect of pan-retinal photocoagulation and intravitreal conbercept treatment on the change of retinal vessel density monitored by optical coherence tomography angiography in patients with proliferative diabetic retinopathy[J/OL]. J Clin Med, 2021, 10(19): 4484[2021-09-29]. https://pubmed.ncbi.nlm.nih.gov/34640502/. DOI: 10.3390/jcm10194484.
21. Huang T, Li X, Xie J, et al. Long-term retinal neurovascular and choroidal changes after panretinal photocoagulation in diabetic retinopathy[J/OL]. Front Med (Lausanne), 2021, 8: 752538[2021-10-18]. https://pubmed.ncbi.nlm.nih.gov/34733867/. DOI: 10.3389/fmed.2021.752538.
22. Takase N, Nozaki M, Kato A, et al. Enlargement of foveal avascular zone in diabetic eyes evaluated by en face optical coherence tomography angiography[J]. Retina, 2015, 35(11): 2377-2383. DOI: 10.1097/IAE.0000000000000849.
23. Siegfried CJ, Shui YB. Intraocular oxygen and antioxidant status: new insights on the effect of vitrectomy and glaucoma pathogenesis[J]. Am J Ophthalmol, 2019, 203: 12-25. DOI: 10.1016/j.ajo.2019.02.008.
24. Stefánsson E, Loftsson T. The stokes-einstein equation and the physiological effects of vitreous surgery[J]. Acta Ophthalmol Scand, 2006, 84(6): 718-719. DOI: 10.1111/j.1600-0420.2006.00778.x.
25. Kim YM, Chung EJ, Byeon SH, et al. Pars plana vitrectomy with internal limiting membrane peeling compared with intravitreal triamcinolone injection in the treatment of diabetic macular edema[J]. Ophthalmologica, 2009, 223(1): 17-23. DOI: 10.1159/000161878.
26. Fossataro F, Rispoli M, Pece A. OCTA in macular intraretinal microvascular abnormalities: Retinal vascular density remodeling after panretinal photocoagulation[J/OL]. Eur J Ophthalmol, 2021: 484559686[2021-11-09]. https://pubmed.ncbi.nlm.nih.gov/34751048/. DOI: 10.1177/11206721211059014.

Chinese Journal of Ocular Fundus Diseases

Macular morphology and vascular parameters changes following micro-invasive vitrectomy in patients with severe non-proliferative diabetic retinopathy

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