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The results of phaco-vitrectomy in patients with proliferative diabetic retinopathy
Bakhritdinova Fazilat Arifovna, Tashkent Medical Academy, Department of eye diseases, Doctor of medicine, Professor E-mail: bakhritdinova@mail.ru Khera Akshey, Ophthalmological Clinic «Vedanta», Ophthalmologist, Tashkent, E-mail: retinauz@gmail.com Arnopolskaya Dina Iosifovna, Cardiologist, Tashkent E-mail: saidakhon.m@mail.ru
The results of phaco-vitrectomy in patients with proliferative diabetic retinopathy
Abstract: In the present research, we considered the effect of diabetic cataract and various variants of its surgical treatment (PHACO+IOL) on structural functional condition of eyes with PDR, which had been subjected to vitreoretinal surgery.
In the process of the research, it was established that the cataract surgery by way of PHACO+IOL, neither isolated, nor in the form of simultaneous operation together with vitrectomy or removal of silicone oil, has no effect on functional outcomes of vitreoretinal surgery of proliferative diabetic retinopathy, level of intraocular pressure and frequency of development of in-travitreal hemorrhages.
Keywords: proliferative diabetic retinopathy, diabetic cataract, phacoemulsification, vitreoretinal surgery.
One of late ophthalmological complications of diabetes includes opacity of transparent lens — development of diabetic cataract. It is related to both, the change of chemical activity of aqueous humor and phenomenon of «sorbitol shunt», which leads to the increase of osmotic properties of lenticular masses, and, with intraocular hemorrhages, development of intraocular hypertension and different ophthalmological interferences — silicone oil tamponade, intravitreal injection of different drugs etc. [1, 868-73].
Goal of the research: study the effect of diabetic cataract and various variants of its surgical treatment (PHACO+IOL) on structural functional condition of eyes with PDR, which had been subjected to vitreoretinal surgery.
Material and method of research. The research included 160 patients (200 eyes) with diabetes complicated with grade IV diabetic retinopathy (proliferative diabetic retinopathy — PDR) admitted for surgical treatment at the clinic of eye microsurgery LLC «KuzTibServis» (Tashkent) and Eye center in Samarkand. All patients were divided into two clinical groups depending on the preceding laser coagulation: the PLC+ group included 116 eyes, on which laser photocoagulation was performed at grade III and early IV of PDR; the group PLC- included 84 eyes without preceding laser coagulation. The indications for operative treatment were: intravitreal hemorrhages that did not resolve within 3-6 months without traction retinal detachment (within 4-6 weeks in case of grade I diabetes or bilateral damage); traction retinal detachment; progressing neovascularization despite pan-retinal laser photocoagulation, massive pre-macular hemorrhage, macula detachment, pre-macular fibrosis, combined retinal detachment, media opacity (including cataract, opacity of posterior capsular, vitreous opacity making laser photocoagulation difficult, neovascularization of iris, anterior hyaloid proliferation, macular edema resistant to laser photocoagulation). All patients included in the research underwent vitreal surgical interference.
Complete ophthalmological examination was performed during primary consultation of the patients on 1, 3 and 10 days
post operation. Long-term results were evaluated after 3, 6, 9 and 12 months. The examination included the determination of the sharpness ofvision, IOP, conditions of anterior chamber, lens, posterior chamber and retina.
Results of the research and discussion. Out of 200 eyes included in the present research, 32 (16%, group IOL) were pseu-dophakic (operation was performed not less than 2 month prior to the inclusion in the research); 26 eyes (13%, group PS) preserved transparent lens till the end of the research. Other eyes, during the period of observation, were subject to phacoemulsification with IOL implantation: on 100 eyes (50%, group PHACO+IOL+VIT) simultaneously with vitrectomy, on 28 eyes (14%, group PHACO+IOL+RemSO) simultaneously with the removal of silicone oil and on 14 eyes (7%, group PHACO+IOL) in the form of isolated interference.
The comparison of sharpness of vision in the groups of patients divided according to the need for cataract surgery revealed the following regularities: although, initial sharpness of vision was comparable in all groups, the sharpness ofvision reduced (n/d compared to the initial data) on the next day post operation in the group PHACO+IOL+RemSO, while it increased in the other groups (accurately with initial data in the group PHACO+IOL+VIT — p<0,001 and in the group PS — p<0,05, n/d in the other groups). As a result, by the 1st post-operation day, the sharpness of vision in the patients of the group PHACO+IOL+RemSO was significantly lower than in the other groups (p<0,05 with the groups IOL and PS and p<0,001 with the group PHACO+IOL+VIT). Apparently, this difference is explained by the fact that in this group, all patients received silicone oil and in the processes of tamponing, increased intraocular pressure is created. Going forward, the sharpness ofvision was progressively increasing in all groups; herewith, in the group PHACO+IOL+RemSO, it remained significantly lower than in the groups PHACO+IOL+VIT and PS. Some reduction was noted by the 3rd month of observation in the group of patients, who had cataract surgery against the background of the removal of SO, which is
Section 7. Medical science
also related to the increase of IOP and lens opacity, which is proved by the augmentation of vision sharpness in the future after the removal of the second operation.
The analysis of IOP depending on the time of cataract surgery demonstrated that IOP was lower in the patients, who preserved the transparent lens throughout the period of observation, compared to the groups of patients, who underwent cataract surgery: thus, during the different periods, the significance of difference with the group IOL accounted for p<0,05 initially and p<0,01 by the end of the 1st month, with the group PHACO+IOL+VIT — p<0,01 initially and p<0,001 during the rest of the period, with the group PHACO+IOL+RemIOL — p<0,01by the end of the first month of observation and with the group PHACO+IOL — p<0,05 by the end of the 6th month of observation.
The share of the patients, who underwent PLC, was comparable in all groups. Also, groups didn't differ in the frequency of occurrence of arterial hypertension, diabetic nephropathy and renal disease, as well as the levels of arterial pressure (SBP and DBP), concentration of urea and creatinine in the peripheral blood and blood sugar concentration. In the group of patients who preserved the transparent lens, the patients with hypertonic crises were slightly rarer. A relatively more stable hypo-dynamics in this group of patients also contributed to the preservation of metabolism of lenticular masses.
Frequency-based comparison of the groups according to the indications for vitreoretinal interference demonstrated the difference in the frequency of occurrence of intravitreal hemorrhages (maximally in patients, who required simultaneous cataract surgery and vitrectomy — 48%). Lens opacity against the background of intravitreal hemorrhages is explained by negative effect ofblood components on lens physiology as well as the tendency for the increase of intraocular pressure (ghost-cell glaucoma) against the background of intravitreal hemorrhages. However, one should note paradoxically high frequency of intravitreal hemorrhages that drove the need in vitrectomy in patients, who preserved transparent lens throughout the entire observation period (46%). Taking into
account the fact that in this group of eyes, minimal value of IOP was noted, the possible explanation can be the following scenario: in the eyes with massive non-relapsive hemorrhages due to incontinuous anamnesis of PDR, significant tractions fail to develop and in the process ofvitreoretinal surgery, there is a rarer need in tamponade of the vitreous cavity. The most rare cases of intravitreal hemorrhages were observed in the group of patients, on whom PHACO+IOL was performed in isolation (14%), i. e. neither by the time of vitrectomy, nor by the time of removal of SO, significant lens opacity was not noted and the development of cataract was determined by metabolic disruptions of aqueous humor related to the main disease. In respect of the frequency of occurrence of other indications for vitrectomy, the groups didn't differ.
Also, we assessed the frequency of application ofvitreous cavity tamponade with silicone oil. It was established that in the group ofpa-tients with pseudophakia at the moment of inclusion in the research, SO tamponade was used in 50% of cases; in the group of simultaneous cataract surgery and vitrectomy — in 42% of cases and significantly rarer in patients, who preserved transparent lens (chi-square = 44,68, p<0,001). Otherwise, neither the duration of vitrectomy (in the group IOL — 79,75±3,13 minutes, PHACO+IOL+VIT — 77,00±2,34 minutes, PHACO+IOL+RemSO — 77,93±3,69 minutes, PHACO+IOL — 70,43±8,27, PS — 79,15±4,84, differences are insignificant), nor the frequency of intra-operational hemorrhagic complications were different between the groups.
In the process of observation, the shares of patients, who required repeated surgical interference (lavage of anterior chamber or re-vitrectomy), were comparable in all groups divided according to cataract surgery.
Thus, the present research showed that surgery by cataract method PHACO+IOL, neither isolated, nor in the form of simultaneous operation together with vitrectomy or removal of silicone oil, has no effect on functional outcomes ofvitreoretinal surgery of proliferative diabetic retinopathy, level of intraocular pressure and frequency of development of intravitreal hemorrhages [2, 31-8; 3, 954-60].
References:
1. Park S.P., AhnJ.K., Lee G.H. Morphologic changes in the anterior segment after phacovitrectomy for proliferative diabetic retinopathy//} Cataract Refract Surg. - 2009 May;35 (5): 868-73.
2. Rivas-Aguiño P., García-Amaris R.A., Berrocal M.H., Sánchez J.G., Rivas A., Arévalo J.F. Pars plana vitrectomy, phacoemulsification and intraocular lens implantation for the management of cataract and proliferative diabetic retinopathy: comparison of a combined versus two-step surgical approach//Arch Soc Esp Oftalmol. - 2009 Jan; 84 (1): 31-8.
3. Shen Y.D., Yang C.M. Extended silicone oil tamponade in primary vitrectomy for complex retinal detachment in proliferative diabetic retinopathy: a long-term follow-up study//Eur J Ophthalmol. - 2007 Nov-Dec; 17 (6): 954-60.
