Comparative evaluation of vitrectomy and dye-enhanced ILM peel with grid laser in diffuse diabetic macular edema

  • Atul KumarEmail author
  • Subijay Sinha
  • Rajvardhan Azad
  • Yog Raj Sharma
  • Rajpal Vohra
Clinical Investigation



The purpose of this study is to compare the effectiveness of pars plana vitrectomy (PPV) and dye-enhanced peeling of the internal limiting membrane (ILM) with modified grid laser photocoagulation in patients with diffuse diabetic macular edema and to determine if any correlation exists between improvement in visual acuity (functional improvement) and reduction in foveal thickness and macular volume (anatomical improvement).


This is a randomized, prospective, comparative, interventional study.


In this study 24 eyes of 24 patients with metabolically stable diabetes and with diffuse diabetic macular edema were evaluated. The patients were randomized to either pars plana vitrectomy with removal of ILM which was done in 12 eyes (ILM group) and modified grid laser photocoagulation carried out in the remaining 12 eyes (laser group). Main outcome measures were (1) the postoperative visual acuity in the form of ETDRS log MAR values, (2) foveal thickness and (3) macular volume as measured by optical coherence tomography. The correlation between improvement in visual acuity and the reduction of foveal thickness and macular volume in both the groups were also evaluated. The results were all subjected to statistical analysis.


The ETDRS log MAR visual acuity difference between the two groups at the end of 6 months was not clinically significant (P = 0.525). However, foveal thickness and macular volume decreased significantly more in the ILM group compared to the laser group (P = 0.001, P < 0.001, Mann Whitney U test). There was no correlation between the improvement in visual acuity and the reduction of foveal thickness (r = −0.158, P = 0.6) (ILM group), r = −0.155, P = 0.7) (laser group) in both groups.


PPV with ILM peeling was shown to be beneficial by inducing a statistically significant reduction of macular thickness and macular volume. Visual acuity also demonstrated a trend towards improvement in both the ILM peel group and the grid laser group; however, the comparative VA outcome analysis between the two groups was not significantly different. Besides, there was also no correlation between the reductions of foveal thickness and macular volume with the improvement in visual acuity in either of the groups.


Diffuse diabetic macular edema Trypan blue enhanced ILM peeling Modified grid laser photocoagulation 


  1. 1.
    Asami T, Terasaki H, Kachi S, Nakamura M, Yamamura K, Nabeshima T, Miyake Y (2004) Ultrastructure of internal limiting membrane removed during plasmin-assisted vitrectomy from eyes with diabetic macular edema. Ophthalmology 111(2):231–237PubMedCrossRefGoogle Scholar
  2. 2.
    Ando F, Yasui O, Hirose H, Ohba N (2004) Optic nerve atrophy after vitrectomy with indocyanine green-assisted internal limiting membrane peeling in diffuse diabetic macular edema. Adverse effect of ICG-assisted ILM peeling. Graefe’s Arch Clin Exp Ophthalmol 242:995–999CrossRefGoogle Scholar
  3. 3.
    Avci R, Kaderli B, Avci B, Simsek S, Baykara M, Kahveci Z, Gelisken O, Yucel AA (2004) Pars plana vitrectomy and removal of the internal limiting membrane in the treatment of chronic macular oedema. Graefes Arch Clin Exp Ophthalmol 242(10):845–852PubMedCrossRefGoogle Scholar
  4. 4.
    Brendan JV, Mathew K, Russell F, Brian CJ (2004) Trypan blue assisted vitrectomy. Retina 24:736–738CrossRefGoogle Scholar
  5. 5.
    Early Treatment Diabetic Retinopathy Study Research Group (1985) Photocoagulation for diabetic macular edema. Early treatment diabetic retinopathy study report number 1. Arch Ophthalmol 103:1796–1806Google Scholar
  6. 6.
    Gandorfer A, Messmer EM, Ulbig MW, Kamplik A (2000) Resolution of diabetic macular edema after surgical removal of the posterior hyaloid and the inner limiting membrane. Retina 20:126–133PubMedCrossRefGoogle Scholar
  7. 7.
    Hikichi T, Fujio N, Akiba Y, Takahashi M, Yoshida A (1997) Association between the short term natural history of diabetic macular edema and the vitreous macular relationship in type 2 diabetes mellitus. Ophthalmology 104:473–478PubMedGoogle Scholar
  8. 8.
    Ikeda T, Sato K, Katano T, Hayashi Y (2000) Improved visual acuity following pars plana vitrectomy for diabetic cystoid macular edema and detached posterior hyaloid. Retina 20:220–222PubMedGoogle Scholar
  9. 9.
    Kamura Y, Sato Y, Isomae T, Shimada H (2005) Effects of internal limiting membrane peeling in vitrectomy on diabetic cystoid macular edema patients. Jpn J Ophthalmol 49(4):297–300PubMedCrossRefGoogle Scholar
  10. 10.
    Klein R, Klein BE, Moss SE, Cruickshanks KJ (1995) The Wisconsin epidemiological study of diabetic retinopathy: XV. The long term incidence of macular edema. Ophthalmology 102:5–16Google Scholar
  11. 11.
    Kolacny D, Parys-Vanginderdeuren R, Van Lommel A, Stalmans P (2005) Vitrectomy with peeling of the inner limiting membrane for treating diabetic macular edema. Bull Soc Belge Ophtalmol (296):15–23PubMedGoogle Scholar
  12. 12.
    Kumagai K, Ogino N, Furukawa M et al (2002) Internal limiting membrane peeling in vitreous surgery for diabetic macular edema. Nippon Ganka Gakkai Zasshi 106(9):590–594PubMedGoogle Scholar
  13. 13.
    La Heij EC, Hendriske F, Kessels AGH, Derhag PJFM (2001) Vitrectomy results in diabetic macular edema without evident vitreomacular traction. Graefes Arch Clin Exp Ophthalmol 239:264–270PubMedGoogle Scholar
  14. 14.
    Lee CM, Olk RJ (1991) Modified grid laser photocoagulation for diffuse diabetic macular edema: long term visual results. Ophthalmology 98:1594–1602PubMedGoogle Scholar
  15. 15.
    Lewis H, Abrams GW, Blumekranz MS, Capo RV (1992) Vitrectomy for diabetic macular traction and edema associated with posterior hyaloidal traction. Ophthalmology 99:753–759PubMedGoogle Scholar
  16. 16.
    Matsunaga N, Ozeki H, Hirabayashi Y, Shimada S, Ogura Y (2005) Histopathologic evaluation of the internal kimiting membrane surgically excised from eyes with diabetic maculopathy. Retina 25:311–316PubMedCrossRefGoogle Scholar
  17. 17.
    Mohan R, Premkumar S, Anitha B, Mohan V (2005) Prevalence of diabetic retinopathy in urban India: The CURES eye study, 1. IOVS 46:2328–2333CrossRefGoogle Scholar
  18. 18.
    Nasrallah FP, Jalkh AE, van Coppenolle F, Kado M, Trempe CL, McMeel JW et al (1988) The role of the vitreous in diabetic macular edema. Ophthalmology 95:1335–1339PubMedGoogle Scholar
  19. 19.
    Olk RJ (1986) Modified grid argon (blue green) laser photocoagulation for diffuse diabetic macular edema. Ophthalmology 93:938–950PubMedGoogle Scholar
  20. 20.
    Otani T, Kishi S (2002) A controlled study of vitrectomy for diabetic macular edema. Am J Ophthalmol 134:214–219PubMedCrossRefGoogle Scholar
  21. 21.
    Patel JI, Hykin PG, Schadt M, Luong V, Fitzke F, Gregor ZJ (2006) Pars plana vitrectomy with and without peeling of the inner limiting membrane for diabetic macular edema. Retina 26(1):5–13PubMedCrossRefGoogle Scholar
  22. 22.
    Pendergast SD, Hassan TS, Williams GA et al (2000) Vitrectomy for diabetic macular edema associated with a thickened and taut posterior hyaloid membrane. Am J Ophthalmol 130:178–186PubMedCrossRefGoogle Scholar
  23. 23.
    Rosenblatt BJ, Shah GK, Sharma S, Bakal J (2005) Pars plana vitrectomy with internal limiting membranectomy for refractory diabetic macular edema without a taut posterior hyaloid. Graefes Arch Clin Exp Ophthalmol 243(1):20–25PubMedCrossRefGoogle Scholar
  24. 24.
    Tachi N, Ogino N (1996) Vitrectomy for diffuse macular edema in cases of diabetic retinopathy. Am J Ophthalmol 122:258–260PubMedGoogle Scholar
  25. 25.
    Thomas D, Bunce C, Moorman C, Laidlaw DA (2005) A randomised controlled feasibility trial of vitrectomy versus laser for diabetic macular oedema. Br J Ophthalmol 89(1):81–86PubMedCrossRefGoogle Scholar
  26. 26.
    Wild S, Roglic G, Green A, King H (2004) Global prevalence of diabetes, estimates for the year 2000 and projections for 2030. Diabetes Care 27:1047–1053PubMedCrossRefGoogle Scholar
  27. 27.
    Yanali A, Nohutcu A, Horozoglu F, Celik E (2005) Modified grid laser photocoagulation versus pars plana vitrectomy with internal limiting membrane peeling in diabetic macular edema. Am J Ophthalmol 139:795–801CrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2006

Authors and Affiliations

  • Atul Kumar
    • 1
    Email author
  • Subijay Sinha
    • 1
  • Rajvardhan Azad
    • 1
  • Yog Raj Sharma
    • 1
  • Rajpal Vohra
    • 1
  1. 1.Vitreous-Retina Service, Dr. Rajendra Prasad Centre for Ophthalmic SciencesAll India Institute of Medical SciencesNew DelhiIndia

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