Skip to main content
SpringerLink
Log in

The Role of Pars Plana Vitrectomy (PPV) for the Treatment of Diabetic Macular Edema (DME)

  • Chapter
  • First Online:
Macular Surgery

  • 479 Accesses

Abstract

Diabetic macular edema (DME) is a major cause of visual morbidity in the USA and developing world [1, 2]. Its prevalence continues to rise due to the expanding diabetic population [3]. The treatment of DME has evolved from focal laser to intravitreal injection of steroids and more recently anti-vascular endothelial growth factor (VEGF) [4–6]. Pars plana vitrectomy (PPV) has been considered a treatment option for DME in various circumstances. It is challenging to make definitive recommendations based on literature reports alone due to the heterogeneity of published studies and limited sample sizes. Meta-analyses attempt to pool data from smaller studies to provide more useful information. We conducted a PubMed search using the terms “pars plana vitrectomy and diabetic macular edema,” “vitrectomy for macular edema,” “vitrectomy and non-tractional diabetic macular edema,” and “vitrectomy and refractory diabetic macular edema.” The search yielded several meta-analyses and review articles [7–18], large series (>50 eyes) [19–41], and smaller series [42–79]. The summaries of the reports are presented here, accounting for variability such as morphology (i.e., with or without traction), previous treatments (laser, steroids), and predisposing factors. We hope that this information can guide the recommendations of practicing clinicians, whose patients are likely equally variable.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 189.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Hardcover Book
USD 249.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

Background

  1. Guariguata L, Whiting DR, Hambleton I, et al. Global estimates of diabetes prevalence for 2013 and projections for 2035. Diabetes Res Clin Pract. 2014;103(2):137–49.

    Article  CAS  Google Scholar 

  2. Bhagat N, Grigorian RA, Tutela A, Zarbin MA. Diabetic macular edema: pathogenesis and treatment. Surv Ophthalmol. 2009;54(1):1–32.

    Article  Google Scholar 

  3. Zhang X, Saaddine JB, Chou C, et al. Prevalence of diabetic retinopathy in the United States, 2005-2008. JAMA. 2010;304(6):649–56.

    Article  CAS  Google Scholar 

  4. Photocoagulation for diabetic macular edema. Early treatment diabetic retinopathy study report number 1. Early diabetic retinopathy study research group. Arch Ophthalmol. 1985;103(12):1796–806.

    Google Scholar 

  5. Ip MS, Bressler SB, Antonszyk AN, et al. A randomized trial comparing intravitreal triamcinolone and focal/grid photocoagulation for diabetic macular edema: baseline features. Retina. 2008;28(7):919–30.

    Article  Google Scholar 

  6. Nguyen QD, Brown DM, Marcus DM, et al. Ranibizumab for diabetic macular edema: results from 2 phase II randomized trials: RISE and RIDE. Ophthalmology. 2012;119(4):789–801.

    Article  Google Scholar 

Meta-analyses and Reviews

  1. Ho T, Smiddy WE, Flynn HW Jr. Vitrectomy in the management of diabetic eye disease. Surv Ophthalmol. 1992;37(3):190–202.

    Article  CAS  Google Scholar 

  2. Lewis H. The role of vitrectomy in the treatment of diabetic macular edema. Am J Ophthalmol. 2001;131(1):123–5.

    Article  CAS  Google Scholar 

  3. Christoforidis JB, D’Amico DJ. Surgical and other treatments of diabetic macular edema: an update. Int Ophthalmol Clin. 2004;44(1):139–60.

    Article  Google Scholar 

  4. Laidlaw DA. Vitrectomy for diabetic macular oedema. Eye (Lond). 2008;22(10):1337–41.

    Article  CAS  Google Scholar 

  5. Smiddy WE. Clinical applications of cost analysis of diabetic macular edema treatments. Ophthalmology. 2012;119(12):2558–62.

    Article  Google Scholar 

  6. Golan S, Loewenstein A. Surgical treatment for macular edema. Semin Ophthalmol. 2014;29(4):242–56.

    Article  Google Scholar 

  7. Simunovic MP, Hunyor AP, Ho IV. Vitrectomy for diabetic macular edema: a systematic review and meta-analysis. Can J Ophthalmol. 2014;49(2):188–95.

    Article  Google Scholar 

  8. Nakajima T, Roggia MF, Noda Y, Ueta T. Effect of internal limiting membrane peeling during vitrectomy for diabetic macular edema: systematic review and meta-analysis. Retina. 2015;35(9):1719–25.

    Article  Google Scholar 

  9. Talcott KE, Modjtahedi BS, Eliott D. Surgical management of diabetic macular edema. Int Ophthalmol Clin. 2015;55(4):123–36.

    Article  Google Scholar 

  10. Crim N, Velez-Montoya R, Morales-Canton V. Surgical versus medical treatment for diabetic macular edema: a review. Med Hypothesis Discov Innov Ophthalmol. 2017;6(5):136–42.

    Google Scholar 

  11. Jackson TL, Nicod E, Angelis A, et al. Pars plana vitrectomy for diabetic macular edema: a systematic review, meta-analysis, and synthesis of safety literature. Retina. 2017;37(5):886–95.

    Article  Google Scholar 

  12. Rinaldi M, dell’Omo R, Morescalchi F, et al. ILM peeling in nontractional diabetic macular edema: review and metanalysis. Int Ophthalmol. 2018;38(6):2709–14.

    Article  CAS  Google Scholar 

Large Series

  1. Murakami T, Nishijima K, Akagi T, et al. Segmentational analysis of retinal thickness after vitrectomy in diabetic macular edema. Invest Ophthalmol Vis Sci. 2012;53(10):6668–74.

    Article  Google Scholar 

  2. Bonnin S, Sandali O, Bonnel S, Monin C, El Sanharawi M. Vitrectomy with interal limiting membrane peeling for tractional and nontractional diabetic macular edema: long-term results of a comparative study. Retina. 2015;35(5):921–8.

    Article  Google Scholar 

  3. Browning DJ, Lee C, Stewart MW, Landers MB 3rd. Vitrectomy for center-involved diabetic macular edema. Clin Ophthalmol. 2016;10:735–42.

    Article  Google Scholar 

  4. DRCR.net Writing Committee, Haller JA, Qin H, et al. Vitrectomy outcomes in eyes with diabetic macular edema and vitreomacular traction. Ophthalmology. 2010;117(6):1087–93.

    Article  Google Scholar 

  5. Flaxel CJ, Edwards AR, Aiello LP, et al. Factors associated with visual acuity outcomes after vitrectomy for diabetic macular edema: diabetic retinopathy clinical research network. Retina. 2010;30(9):1488–95.

    Article  Google Scholar 

  6. Pendergast SD, Hassan TS, Williams GA, et al. Vitrectomy for diffuse diabetic macular edema associated with a taut premacular posterior hyaloid. Am J Ophthalmol. 2000;130(2):178–86.

    Article  CAS  Google Scholar 

  7. Kumagai K, Furukawa M, Ogino N, et al. Long-term follow-up of vitrectomy for diffuse nontractional diabetic macular edema. Retina. 2009;29(4):464–72.

    Article  Google Scholar 

  8. Yamamoto T, Takeuchi S, Sato Y, Yamashita H. Long-term follow-up results of pars plana vitrectomy for diabetic macular edema. Jpn J Ophthalmol. 2007;51(4):285–91.

    Article  Google Scholar 

  9. Ikeda T, Sato K, Katano T, Hayashi Y. Improved visual acuity following pars plana vitrectomy for diabetic cystoid macular edema and detached posterior hyaloid. Retina. 2000;20(2):220–2.

    Article  CAS  Google Scholar 

  10. Kralinger MT, Pedri M, Kralinger F, Troger J, Kieselbach GF. Long-term outcome after vitrectomy for diabetic macular edema. Ophthalmologica. 2006;220(3):147–52.

    Article  Google Scholar 

  11. Romano MR, Roman V, Vallejo-Garcia JL, et al. Macular hypotrophy after internal limiting membrane removal for diabetic macular edema. Retina. 2014;34(6):1182–9.

    Article  Google Scholar 

  12. Stolba U, Binder S, Gruber D, Krebs I, Aggerman T, Neumaier B. Vitrectomy for persistent diffuse diabetic macular edema. Am J Ophthalmol. 2005;140(2):295–301.

    Article  Google Scholar 

  13. Asahina Y, Tachi N, Asahina Y, et al. Six-month postoperative outcomes of intraoperative OCT-guided surgical cystotomy for refractory cystoid macular edema in diabetic eyes. Clin Ophthalmol. 2017;11:2099–105. eCollection 2017.

    Article  CAS  Google Scholar 

  14. Bahadir M, Ertan A, Mertoglu O. Visual acuity comparison of vitrectomy with and without internal limiting membrane removal in the treatment of diabetic macular edema. Int Ophthalmol. 2005;26(1–2):3–8.

    Google Scholar 

  15. Iglicki M, Lavaque A, Ozimek M, et al. Biomarkers and predictors for functional and anatomic outcomes for small gauge pars plana vitrectomy and peeling of the internal limiting membrane in naïve diabetic macular edema: the VITAL Study. PLoS One. 2018;13(7):e0200365. eCollection 2018.

    Article  CAS  Google Scholar 

  16. Kalvoda J, Duskova J, Kubena A, Povysil C, Kalvodova B. Morphometry of surgically removed internal limiting membrane during vitrectomy in diabetic macular edema. Graefes Arch Clin Exp Ophthalmol. 2009;247(10):1307–14.

    Article  Google Scholar 

  17. Kumagai K, Hangai M, Ogino N, Larson E. Effect of internal limiting membrane peeling on long-term visual outcomes for diabetic macular edema. Retina. 2015;35(7):1422–8.

    Article  Google Scholar 

  18. Yamakoshi T, Kachi S, Sugita J, et al. Triamcinolone-assisted removal of internal limiting membrane enhances the effect of vitrectomy for diabetic macular edema. Ophthalmic Res. 2009;41(4):203–9.

    Article  CAS  Google Scholar 

  19. Yoshikawa M, Murakami T, Nishijima K, et al. Macular migration toward the optic disc after inner limiting membrane peeling for diabetic macular edema. Invest Ophthalmol Vis Sci. 2013;54(1):629–35.

    Article  Google Scholar 

  20. Kogo J, Shiono A, Sasaki H, et al. Foveal microstructure analysis in eyes with diabetic macular edema treated with vitrectomy. Adv Ther. 2017;34(9):2139–49. Epub 2017 Aug 14.

    Article  Google Scholar 

  21. Ichiyama Y, Sawada O, Mori T, et al. The effectiveness of vitrectomy for diffuse diabetic macular edema may depend on its preoperative optical coherence tomography pattern. Graefes Arch Clin Exp Ophthalmol. 2016;254(8):1545–51.

    Article  Google Scholar 

  22. Kim J, Kang SW, Shin DH, et al. Macular ischemia and outcome of vitrectomy for diabetic macular edema. Jpn J Ophthalmol. 2015;59(5):295–304.

    Article  Google Scholar 

  23. Uji A, Murakami T, Suzuma K. Influence of vitrectomy surgery on the integrity of outer retinal layers in diabetic macular edema. Retina. 2018;38(1):163–72.

    Article  Google Scholar 

Smaller Series

  1. Matsunaga N, Ozeki H, Hirabayashi Y, Shimada S, Ogura Y. Histopathologic evaluation of the internal limiting membrane surgically excised from eyes with diabetic maculopathy. Retina. 2005;25(3):311–6.

    Article  Google Scholar 

  2. Abdel Hadi AM. Evaluation of vitrectomy with planned foveal detachment as surgical treatment for refractory diabetic macular edema with or without vitreomacular interface abnormality. J Ophthalmol. 2018;2018:9246384. eCollection 2018.

    Article  Google Scholar 

  3. Gungel H, Altan C, Baylancicek DO, et al. The effects of 23-gauge pars plana vitrectomy on orbital circulation using doppler ultrasonography in diabetic macular edema with epiretinal membrane and taut posterior hyaloid. Curr Eye Res. 2017;42(1):118–24.

    Article  Google Scholar 

  4. Lewis H, Abrams GW, Blumenkranz MS, Campo RV. Vitrectomy for diabetic macular traction and edema associated with posterior hyaloid traction. Ophthalmology. 1992;99(5):753–9.

    Article  CAS  Google Scholar 

  5. Yamamoto T, Akabane N, Takeuchi S. Vitrectomy for diabetic macular edema: the role of posterior vitreous detachment and epimacular membrane. Am J Ophthalmol. 2001;132(3):369–77.

    Article  CAS  Google Scholar 

  6. Patel JI, Hykin PG, Schadt M, Luong V, Fitzke F, Gregor ZJ. Pars plana vitrectomy for diabetic macular oedema: OCT and functional correlations. Eye (Lond). 2006;20(6):674–80.

    Article  CAS  Google Scholar 

  7. Yoshizumi Y, Ohara Z, Tabuchi H, et al. Effects of kallidinogenase in patients undergoing vitrectomy for diabetic macular edema. Int Ophthalmol. 2018;39(6):1307–13.

    Article  Google Scholar 

  8. Figueroa MS, Contreras I, Noval S. Surgical and anatomical outcomes of pars plana vitrectomy for diffuse nontractional diabetic macular edema. Retina. 2008;28(3):420–6.

    Article  Google Scholar 

  9. Michalewska Z, Stewart MW, Lander MB 3rd, et al. Vitrectomy in the management of diabetic macular edema in treatment-naïve patients. Can J Ophthalmol. 2018;53(4):402–7.

    Article  Google Scholar 

  10. Ghassemi F, Bazvand F, Roohipoor R, et al. Outcomes of vitrectomy, membranectomy and internal limiting membrane peeling in patients with refractory diabetic macular edema and non-tractional epiretinal membrane. J Curr Ophthalmol. 2016;28(4):199–205.

    Article  Google Scholar 

  11. Ikeda T, Sato K, Katano T, Hayashi Y. Vitrectomy for cystoid macular oedema with attached posterior hyaloid membrane in patients with diabetes. Br J Ophthalmol. 1999;83(1):12–4.

    Article  CAS  Google Scholar 

  12. Navarrete-Sanchis J, Zarco-Bosquets J, Tomas-Torrent JM, Diago T, Ortega-Evangelio L. Long-term effectiveness of vitrectomy in diabetic cystoid macular edema. Graefes Arch Clin Exp Ophthalmol. 2015;253(5):713–9.

    Article  Google Scholar 

  13. Rosenblatt BJ, Shah GK, Sharma S, Bakal J. Pars plana vitrectomy with internal limiting membranectomy for refractory diabetic macular edema without a taut posterior hyaloid. Graefes Arch Clin Exp Ophthalmol. 2005;243(1):20–5.

    Article  Google Scholar 

  14. Recchia FM, Ruby AJ, Carvalho Recchia CA. Pars plana vitrectomy with removal of the internal limiting membrane in the treatment of persistent diabetic macular edema. Am J Ophthalmol. 2005;139(3):447–54.

    Article  Google Scholar 

  15. Yanyali A, Horozoglu F, Celik E, Ercalik Y, Nohutcu AF. Pars plana vitrectomy and removal of the internal limiting membrane in diabetic macular edema unresponsive to grid laser photocoagulation. Eur J Ophthalmol. 2006;16(4):573–81.

    Article  CAS  Google Scholar 

  16. Gentile RC, Milman T, Eliott D, Romero JM, McCormick SA. Taut internal limiting membrane causing diffuse diabetic macular edema after vitrectomy: clinicopathological correlation. Ophthalmologica. 2011;226(2):64–70.

    Article  Google Scholar 

  17. Hartely KL, Smiddey WE, Flynn HW Jr, Murray TG. Pars plana vitrectomy with internal limiting membrane peeling for diabetic macular edema. Retina. 2008;28(3):410–9.

    Article  Google Scholar 

  18. Hoerauf H, Bruggeman A, Muecke M, et al. Pars plana vitrectomy for diabetic macular edema. Internal limiting membrane delamination vs posterior hyaloid removal. A prospective randomized trial. Graefes Arch Clin Exp Ophthalmol. 2011;249(7):997–1108.

    Article  Google Scholar 

  19. Jahn CE, Topfner von Schutz K, Richter J, Boller J, Kron M. Improvement of visual acuity in eyes with diabetic macular edema after treatment with pars plana vitrectomy. Ophthalmologica. 2004;218(6):378–84.

    Article  Google Scholar 

  20. Kimura T, Kiryu J, Nishiwaki H, Oh H, Suzuma K, Watanabe D, Kurimoto M, Takagi H. Efficacy of surgical removal of the internal limiting membrane in diabetic cystoid macular edema. Retina. 2005;25(4):454–61.

    Article  Google Scholar 

  21. Patel JI, Hykin PG, Schadt M, Luong V, Fitzke F, Gregor ZJ. Pars plana vitrectomy with and without peeling of the inner limiting membrane for diabetic macular edema. Retina. 2006;26(1):5–13.

    Article  Google Scholar 

  22. Tamura K, Yokoyama T, Ebihara N, Murakami A. Histopathologic analysis of the internal limiting membrane surgically peeled from eyes with diffuse diabetic macular edema. Jpn J Ophthalmol. 2012;56(3):280–7.

    Article  Google Scholar 

  23. Yamamoto T, Hitani K, Sato Y, Yamashita H, Takeuchi S. Vitrectomy for diabetic macular edema with and without internal limiting membrane removal. Ophthalmologica. 2005;219(4):206–13.

    Article  Google Scholar 

  24. Yanyali A, Horozoglu F, Celik E, Nohutcu AF. Long-term outcomes of pars plana vitrectomy with internal limiting membrane removal in diabetic macular edema. Retina. 2007;27(5):557–66.

    Article  Google Scholar 

  25. Yoshitake S, Murakami T, Uji A, et al. Association between cystoid spaces on indocyanine green hyperfluorescence and optical coherence tomography after vitrectomy for diabetic macular oedema. Eye (Lond). 2014;28(4):439–48.

    Article  CAS  Google Scholar 

  26. Raizada S, Al Kandari J, Al Diab F, et al. Pars plana vitrectomy versus three intravitreal injections of bevacizumab for nontractional diabetic macular edema. A prospective, randomized comparative study. Indian J Ophthalmol. 2015;63(6):504–10.

    Article  Google Scholar 

  27. Doi N, Sakamoto T, Sonoda Y, et al. Comparative study of vitrectomy versus intravitreous triamcinolone for diabetic macular edema on randomized paired-eyes. Graefes Arch Clin Exp Ophthalmol. 2012;250(1):71–8.

    Article  CAS  Google Scholar 

  28. Higuchi A, Ogata N, Jo N, Wada M, Matsumura M. Pars plana vitrectomy with removal of posterior hyaloid face in treatment of refractory diabetic macular edema resistant to triamcinolone acetonide. Jpn J Ophthalmol. 2006;50(6):529–31.

    Article  Google Scholar 

  29. Chhablani JK, Kim JS, Cheng L, Kozak I, Freeman WV. External limiting membrane as a predictor of visual improvement in diabetic macular edema after pars plana vitrectomy. Graefes Arch Clin Exp Ophthalmol. 2012;250(10):1415–20.

    Article  Google Scholar 

  30. Giovannini A, Amato G, Mariotti C, Scassellati-Sforzolini B. Optical coherence tomography findings in diabetic macular edema before and after vitrectomy. Ophthalmic Surg Lasers. 2000;31(3):187–91.

    CAS  Google Scholar 

  31. Hatano N, Mizota A, Tanaka M. Vitreous surgery for diabetic macular edema—its prognosis and correlation between preoperative systemic and ocular conditions and visual outcome. Ann Ophthalmol (Skokie). 2007;39(3):222–7.

    Article  Google Scholar 

  32. Ma J, Yao K, Jiang J, Wu D, Gao R, Yin J, Fang X. Assessment of macular function by multifocal electroretinogram in diabetic macular edema before and after vitrectomy. Doc Ophthalmol. 2004;109(2):131–7.

    Article  Google Scholar 

  33. Nishijima K, Murakami T, Hirashima T, et al. Hyperreflective foci in outer retina predictive of photoreceptor damage and poor vision after vitrectomy for diabetic macular edema. Retina. 2014;34(4):732–40.

    Article  Google Scholar 

  34. Park JH, Woo SJ, Ha YJ, Yu H. Effect of vitrectomy of macular microcirculation in patients with diffuse diabetic macular edema. Graefes Arch Clin Exp Ophthalmol. 2009;247(8):1009–17.

    Article  Google Scholar 

  35. Shah SP, Patel M, Thomas D, Aldington S, Laidlaw DA. Factors predicting outcome of vitrectomy for diabetic macular oedema: results of a prospective study. Br J Ophthalmol. 2006;90(1):33–6.

    Article  CAS  Google Scholar 

  36. Teresaki H, Kojima T, Niwa H, Piao CH, Ueno S, Kondo M, Ito Y, Miyake Y. Changes in focal macular electroretinograms and foveal thickness after vitrectomy for diabetic macular edema. Invest Ophthalmol Vis Sci. 2003;44(10):4465–72.

    Article  Google Scholar 

  37. Wakabayashi Y, Kimura K, Muramatsu D, et al. Axial length as a factor associated with visual outcome after vitrectomy for diabetic macular edema. Invest Ophthalmol Vis Sci. 2013;54(10):6834–40.

    Article  Google Scholar 

  38. Yamada Y, Suzuma K, Ryu M, et al. Systemic factors influence the prognosis of diabetic macular edema after pars plana vitrectomy with internal limiting membrane peeling. Curr Eye Res. 2013;38(12):1261–5.

    Article  Google Scholar 

Other

  1. Christoforidis JB, Williams MM, Wang J, et al. Anatomic and pharmacokinetic properties of intravitreal bevacizumab and ranibizumab after vitrectomy and lensectomy. Retina. 2013;33(5):946–52.

    Article  CAS  Google Scholar 

  2. Falavarjani KG, Nguyen QD. Adverse events and complications associated with intravitreal injection of anti-VEGF agents: a review of literature. Eye (Lond). 2013;27(7):787–94.

    Article  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Ophthalmology and Vision Science, University of California, Davis, Sacramento, CA, USA

    Lekha Mukkamala, R. Joel Welch & Lawrence S. Morse

Authors
  1. Lekha Mukkamala
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. R. Joel Welch
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Lawrence S. Morse
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Lawrence S. Morse .

Editor information

Editors and Affiliations

  1. Sydney Retina Clinic and Sydney Eye Hospital, Sydney, NSW, Australia

    Andrew Chang

  2. Department of Ophthalmology and Visual Sciences, The University of Illinois at Chicago, Chicago, IL, USA

    William F. Mieler

  3. Department of Ophthalmology, Shiga University of Medical Science, Shiga, Japan

    Masahito Ohji

Rights and permissions

Reprints and permissions

Copyright information

© 2020 The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd.

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Mukkamala, L., Welch, R.J., Morse, L.S. (2020). The Role of Pars Plana Vitrectomy (PPV) for the Treatment of Diabetic Macular Edema (DME). In: Chang, A., Mieler, W.F., Ohji, M. (eds) Macular Surgery. Springer, Singapore. https://doi.org/10.1007/978-981-15-7644-7_26

Download citation

  • DOI: https://doi.org/10.1007/978-981-15-7644-7_26

  • Published:

  • Publisher Name: Springer, Singapore

  • Print ISBN: 978-981-15-7642-3

  • Online ISBN: 978-981-15-7644-7

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation