15.1  Indications for Vitrectomy in Diabetic Retinopathy

Vitrectomy in diabetic retinopathy is most commonly indicated for non-clearing vitreous hemorrhage, tractional retinal detachment threatening the macula, and combined tractional-rhegmatogenous retinal detachment.

Indications for Vitrectomy in Diabetic Retinopathy

  1. Vitreous hemorrhage that is persistent or recurrent (the most common indication). Consider the following criteria to determine the need for, and urgency of surgery:
    1. Presence / lack of prior treatment (laser)
    2. VH in an only eye (Figure 15.1.1)
    3. Presence of anterior segment neovascularization (decreases chances of spontaneous clearance)
    4. Vitrectomy will decrease the durability of anti-VEGF agents; therefore, some surgeons are reluctant to perform a vitrectomy unless VH does not clear after several months. Anti-VEGF therapy can be used before considering surgery to support spontaneous clearance. However, if there is significant neovascularization this risks accelerating fibrosis and tractional retinal detachment
      1. DRCR.net Protocol AB compared aflibercept versus prompt vitrecomy with PRP in eyes with vitreous hemorrhage from PDR. Although initial visual recovery was faster with vitrectomy, the study found no significant difference in visual acuity outcomes long-term, confirming that both vitrectomy and early anti-VEGF are viable treatment options[1]
  2. Tractional retinal detachment (TRD) threatening the macula (Figure 15.1.2). Some patients may have stable extrafoveal diabetic TRDs- documented progression is preferred before operating
  3. Combined tractional-rhegmatogenous retinal detachment

Figure 15.1.1 Non-clearing Dense Vitreous Hemorrhage

Figure 15.1.2 Tractional Retinal Detachment Threatening the Macular with Subhyaloid Hemorrhage

Figure 15.1.3 Premacular Hemorrhage with Neovascularisation

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