Surgical Management of Proliferative Diabetic Retinopathy

Abstract

Treating patients with severe nonproliferative diabetic retinopathy (PDR) or early PDR with panretinal photocoagulation and/or injections of anti-vascular endothelial growth factor may stabilize progression of retinopathy. However, despite such attempts at intervention and depending on the severity of disease at initial presentation as well as its progression, there are patients who will require surgical intervention. Advances in vitreoretinal surgery have made it possible to improve outcomes in eyes with advanced PDR that were once considered inoperable. Current indications for surgery include chronic or recurrent unilateral vitreous hemorrhage, premacular subhyaloidal hemorrhage, bilateral vitreous hemorrhage, tractional retinal detachment, and neovascular glaucoma. A proper and thorough evaluation during the initial encounter allows for the surgeon to set appropriate goals for the surgery and the patient's expectations of the surgical outcome. The goals of surgery for PDR include removal of vitreous opacities, specifically hemorrhage, dissection of fibrovascular tissue to relieve traction on the posterior pole, reattachment of the tractional and/or rhegmatogenous retinal detachment, and prevention of recurrent proliferative disease by means of completion of panretinal photocoagulation. If these goals are accomplished, the retina should reattach and recurrence of proliferative disease should be minimal. However, postoperative complications such as advancement of cataract, recurrent vitreous hemorrhage, macular edema, rhegmatogenous retinal detachment, and glaucoma can and do occur. A successful surgical outcome for these patients requires a comprehensive evaluation preoperatively, proper preoperative medical management, appropriate counseling, and meticulous surgical intervention accompanied by detailed postoperative care and good patient compliance.