Introduction:

Macular edema is the main cause of visual loss in diabetic patients. In spite of the ample choice of therapeutic modalities, chronic macular edema management is a challenge to this date. Aside from laser and intravitreal therapies, the newest proposal by some authors has been vitrectomy with ILM peeling as a possible solution for many therapy-resistant cases, or even naive cases. Reducing traction, increasing retinal oxygenation and inducing a retinal remodelling response are proposed mechanisms to reduce macular edema.

Methods:

The authors defend that the management of diffuse macular edema should still be, on a first approach, a medical one. Medical therapy has a favourable safety profile, ample experience and multiple well-documented and ongoing studies that support their effectiveness and role in reversing the vascular changes in the diabetic retina. Vitrectomy and ILM peeling, however, have a less favourable safety profile, induce microperimetric changes with unknown long-term consequences and may have an effect on the safety and pharmacokinetics of future therapies (such as Dexamethasone implants or Anti-VEGF). The authors prefer to use the initial approach of intravitreal dexamethasone implants, isolated or combined with anti-VEGF or laser therapy in selected cases, reserving vitrectomy for patients with concurrent ERM, VMT or an otherwise unresponsive macular edema. To support this claim, we present our experience with ozurdex® implants for chronic DME in over 30 patients, as well a s clinical cases of vitrectomy in difficult cases.

Conclusions:

Vitrectomy surely has a role in the management of DME. However, before an invasive procedure can be considered as a widespread solution for naive and possibly younger patients, more studies should be performed and caution is advisable.

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Pedro Neves