Subretinal injection of balanced salt solution for the resolution of refractory diabetic macular edema_Chinese Journal of Ocular Fundus Diseases

Authors：

Zeng Miao ,  Chen Xiao , Hong Ling , Ding Qin , Huang Zhijian

Department of Ophtalmology, Central Theater Command General Hospital of Chinese People's Liberation Army, Wuhan 430070, China;

Corresponding author：

Chen Xiao, Email: cxfn817@163.com

Keywords：

Macular edema/therapy; Diabetic retinopathy; Vitrectomy; Subretinal injection; Balanced salt solution

DOI：

10.3760/cma.j.cn511434-20190304-00065

Video：

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Objective To evaluate the therapeutic efficacy of vitrectomy with internal limiting membrane (ILM) peeling and subretinal injection of balance salt solution (BSS) for refractory diabetic macular edema (DME).Methods A retrospective case series study. From November 2017 to August 2018, 24 eyes of 19 patients affected with DME resistant to anti-VEGF therapy [central macualar thickness (CMT) more than 275 μm despite undergoing anti-VEGF therapy at least 3 times] in Ophtalmology Department of Central Theater Command General Hospital of Chinese People's Liberation Army were enrolled in this study. All the patients underwent 25G pars plana vitrectomy with ILM peeling and subretinal injection of BSS. The BCVA was measured using the international standard visual acuity chart, and the results were converted to the logMAR visual acuity. The CMT and the macular volume (MV) were assessed with swept-source optical coherence tomography at baseline and each month postoperatively. The differences in BCVA, CMT and MV before and after surgery were analyzed.Results The mean BCVA was 0.74±0.29 at baseline, which increased significantly to 0.62±0.28, 0.56±0.25, 0.47±0.26, 0.46±0.23 at 2 weeks, 1 month, 3 months and 6 months after treatment respectively (F=4.828, P=0.001). At 6 months, BCVA improved by more than 0.3 logMAR units in 16 eyes (66.7%). The mean CMT was 554.58±102.86 μm at baseline, which reduced to 338.17±58.09 μm, 299.42±52.66 μm, 275.75±41.24 μm and 270.96±38.33 μm at 2 weeks, 1 month, 3 months and 6 months after treatment respectively (F=84.867, P＜0.001). The mean MV was 13.01±0.88 mm³ at baseline, which decreased to 11.50±0.73 mm³, 11.00±0.74 mm³, 10.68±0.61 mm³ and 10.52±0.56 mm³ at 2 weeks, 1 month, 3 months and 6 months after treatment respectively (F=47.364, P＜0.001). Macular edema recurred in 5 eyes (20.8%) 6 months after surgery. No severe systemic or ocular side effect was reported during the follow-up.Conclusions 25G vitrectomy with ILM peeling and subretinal injection of BSS for refractory DME can improve the visual acuity, facilitate a rapid resolution of macular edema.

Citation： Zeng Miao, Chen Xiao, Hong Ling, Ding Qin, Huang Zhijian. Subretinal injection of balanced salt solution for the resolution of refractory diabetic macular edema. Chinese Journal of Ocular Fundus Diseases, 2020, 36(6): 462-466. doi: 10.3760/cma.j.cn511434-20190304-00065 Copy

1.	Bhagat N, Grigorian RA, Tutela A, et al. Diabetic macular edema: pathogenesis and treatment[J]. Surv Ophthalmol, 2009, 54(1): 1-32. DOI: 10.1016/j.survophthal.2008.10.001.
2.	Brown DM, Nguyen QD, Marcus DM, et al. Long-term outcomes of ranibizumab therapy for diabetic macular edema: the 36-month results from two phase Ⅲ trials: RISE and RIDE[J]. Ophthalmology, 2013, 120(10): 2013-2022. DOI: 10.1016/j.ophtha.2013.02.034.
3.	Korobelnik JF, Do DV, Schmidt-Erfurth U, et al. Intravitreal aflibercept for diabetic macular edema[J]. Ophthalmology, 2014, 121(11): 2247-2254. DOI: 10.1016/j.ophtha.2014.05.006.
4.	Heier JS, Korobelnik JF, Brown DM, et al. Intravitreal aflibercept for diabetic macular edema: 148-week results from the VISTA and VIVID studies[J]. Ophthalmology, 2016, 123(11): 2376-2385. DOI: 10.1016/j.ophtha.2016.07.032.
5.	Nguyen QD, Brown DM, Marcus DM, et al. Ranibizumab for diabetic macular edema: results from 2 phase Ⅲ randomized trials: RISE and RIDE[J]. Ophthalmology, 2012, 119(4): 789-801. DOI: 10.1016/j.ophtha.2011.12.039.
6.	Yanagida Y, Ueta T. Systemic safety of ranibizumab for diabetic macular edema: meta-analysis of randomized trials[J]. Retina, 2014, 34(4): 629-635. DOI: 10.1097/IAE.0000000000000116.
7.	Morizane Y, Kimura S, Hosokawa M, et al. Planned foveal detachment technique for the resolution of diffuse diabetic macular edema[J]. Jpn J Ophthalmol, 2015, 59(5): 279-287. DOI: 10.1007/s10384-015-0390-4.
8.	Frank RN. Diabetic retinopathy[J]. N Engl J Med, 2004, 350(1): 48-58. DOI: 10.1056/NEJMra021678.
9.	Das A, McGuire PG, Rangasamy S. Diabetic macular edema: pathophysiology and novel therapeutic targets[J]. Ophthalmology, 2015, 122(7): 1375-1394. DOI: 10.1016/j.ophtha.2015.03.024.
10.	Terasaki H, Ogura Y, Kitano S, et al. Management of diabetic macular edema in Japan: a review and expert opinion[J]. Jpn J Ophthalmol, 2018, 62(1): 1-23. DOI: 10.1007/s10384-017-0537-6.
11.	Urias EA, Urias GA, Monickaraj F, et al. Novel therapeutic targets in diabetic macular edema: beyond VEGF[J]. Vision Res, 2017, 139(10): 221-227. DOI: 10.1016/j.visres.2017.06.015.
12.	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]. J Curr Ophthalmol, 2016, 28(4): 199-205. DOI: 10.1016/j.joco.2016.08.006.
13.	Yamamoto T, Hitani K, Tsukahara I, et al. Early postoperative retinal thickness changes and complications after vitrectomy for diabetic macular edema[J]. Am J Ophthalmol, 2003, 135(1): 14-19. DOI: 10.1016/S0002-9394(02)01819-6.
14.	Yanyali A, Horozoglu F, Celik E, et al. Long-term outcomes of pars plana vitrectomy with internal limiting membrane removal in diabetic macular edema[J]. Retina, 2007, 27(5): 557-566. DOI: 10.1097/01.iae.0000249390.61854.d5.
15.	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/OL]. J Ophthalmol, 2018, 2018: 9246384[2018-05-07]. https://doi.org/10.1155/2018/9246384. DOI: 10.1155/2018/9246384.
16.	Toshima S, Morizane Y, Kimura S, et al. Planned foveal detachment technique for the resolution of diabetic macular edema resistant to anti–vascular endothelial growth factor therapy[J]. Retina, 2019, 39 Suppl 1: S162-168. DOI: 10.1097/IAE.0000000000001771.
17.	Michalewska Z, Stewart MW, Landers MB 3rd, et al. Vitrectomy in the management of diabetic macular edema in treatment-naïve patients[J]. Can J Ophthalmol, 2018, 53(4): 402-407. DOI: 10.1016/j.jcjo.2017.10.011.

1. Bhagat N, Grigorian RA, Tutela A, et al. Diabetic macular edema: pathogenesis and treatment[J]. Surv Ophthalmol, 2009, 54(1): 1-32. DOI: 10.1016/j.survophthal.2008.10.001.
2. Brown DM, Nguyen QD, Marcus DM, et al. Long-term outcomes of ranibizumab therapy for diabetic macular edema: the 36-month results from two phase Ⅲ trials: RISE and RIDE[J]. Ophthalmology, 2013, 120(10): 2013-2022. DOI: 10.1016/j.ophtha.2013.02.034.
3. Korobelnik JF, Do DV, Schmidt-Erfurth U, et al. Intravitreal aflibercept for diabetic macular edema[J]. Ophthalmology, 2014, 121(11): 2247-2254. DOI: 10.1016/j.ophtha.2014.05.006.
4. Heier JS, Korobelnik JF, Brown DM, et al. Intravitreal aflibercept for diabetic macular edema: 148-week results from the VISTA and VIVID studies[J]. Ophthalmology, 2016, 123(11): 2376-2385. DOI: 10.1016/j.ophtha.2016.07.032.
5. Nguyen QD, Brown DM, Marcus DM, et al. Ranibizumab for diabetic macular edema: results from 2 phase Ⅲ randomized trials: RISE and RIDE[J]. Ophthalmology, 2012, 119(4): 789-801. DOI: 10.1016/j.ophtha.2011.12.039.
6. Yanagida Y, Ueta T. Systemic safety of ranibizumab for diabetic macular edema: meta-analysis of randomized trials[J]. Retina, 2014, 34(4): 629-635. DOI: 10.1097/IAE.0000000000000116.
7. Morizane Y, Kimura S, Hosokawa M, et al. Planned foveal detachment technique for the resolution of diffuse diabetic macular edema[J]. Jpn J Ophthalmol, 2015, 59(5): 279-287. DOI: 10.1007/s10384-015-0390-4.
8. Frank RN. Diabetic retinopathy[J]. N Engl J Med, 2004, 350(1): 48-58. DOI: 10.1056/NEJMra021678.
9. Das A, McGuire PG, Rangasamy S. Diabetic macular edema: pathophysiology and novel therapeutic targets[J]. Ophthalmology, 2015, 122(7): 1375-1394. DOI: 10.1016/j.ophtha.2015.03.024.
10. Terasaki H, Ogura Y, Kitano S, et al. Management of diabetic macular edema in Japan: a review and expert opinion[J]. Jpn J Ophthalmol, 2018, 62(1): 1-23. DOI: 10.1007/s10384-017-0537-6.
11. Urias EA, Urias GA, Monickaraj F, et al. Novel therapeutic targets in diabetic macular edema: beyond VEGF[J]. Vision Res, 2017, 139(10): 221-227. DOI: 10.1016/j.visres.2017.06.015.
12. 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]. J Curr Ophthalmol, 2016, 28(4): 199-205. DOI: 10.1016/j.joco.2016.08.006.
13. Yamamoto T, Hitani K, Tsukahara I, et al. Early postoperative retinal thickness changes and complications after vitrectomy for diabetic macular edema[J]. Am J Ophthalmol, 2003, 135(1): 14-19. DOI: 10.1016/S0002-9394(02)01819-6.
14. Yanyali A, Horozoglu F, Celik E, et al. Long-term outcomes of pars plana vitrectomy with internal limiting membrane removal in diabetic macular edema[J]. Retina, 2007, 27(5): 557-566. DOI: 10.1097/01.iae.0000249390.61854.d5.
15. 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/OL]. J Ophthalmol, 2018, 2018: 9246384[2018-05-07]. https://doi.org/10.1155/2018/9246384. DOI: 10.1155/2018/9246384.
16. Toshima S, Morizane Y, Kimura S, et al. Planned foveal detachment technique for the resolution of diabetic macular edema resistant to anti–vascular endothelial growth factor therapy[J]. Retina, 2019, 39 Suppl 1: S162-168. DOI: 10.1097/IAE.0000000000001771.
17. Michalewska Z, Stewart MW, Landers MB 3rd, et al. Vitrectomy in the management of diabetic macular edema in treatment-naïve patients[J]. Can J Ophthalmol, 2018, 53(4): 402-407. DOI: 10.1016/j.jcjo.2017.10.011.

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Subretinal injection of balanced salt solution for the resolution of refractory diabetic macular edema

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