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Vitrectomy in Diabetic Patients with Chronic Kidney Disease and Diabetic Retinopathy

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  • Mexican Institute of Ophthalmology, Queretaro, Mexico
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Vitrectomy in Diabetic Patients with Chronic Kidney Disease and Diabetic Retinopathy

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Purpose: To describe the anatomic and functional outcomes in patients with chronic kidney disease who underwent pars plana vitrectomy for proliferative diabetic retinopathy. Methods: We retrospectively reviewed the medical records of patients with chronic kidney disease who underwent 25-gauge vitrectomy for diabetic vitreous hemorrhage and/or tractional retinal detachment between January 2017 and March 2018. Visual outcome, intraocular pressure and complications were documented.Results: The postoperative refractive error calculated by A-scan was-0.72 ± 0.96 diopters and that calculated by optic biometry was-0.13 ± 0.83 diopters in patients with age-related macular degeneration. Higher myopic shifts were observed with A-scan measurements than with optical biometry measurements. Results: 68 eyes of 57 patients. The median GFR was 19.9 ml/min/1.73m2 (IQR: 7.45-41.65). Preoperative best corrected visual acuity was ≤ 20/400 in 53 (77.94%) eyes. Postoperative BCVA at the end of the follow-up was ≥ 20/200 in 28 (41.17%) eyes, and ≥ 20/40 in 3 (4.41%) eyes. Main intraoperative complications were retinotomies in 14 (20.58%) eyes and active bleeding in 3 (4.42%) eyes. Main postoperative complications were postoperative vitreous cavity hemorrhage in 14 (20.59%) eyes, ocular hypertension in 9 (13.24%) eyes, and corneal epithelial defect in 9 (13.24%) eyes. Conclusion: Vitrectomy in patients with chronic kidney disease and diabetic retinopathy can be performed with favorable anatomical and functional results.
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OPEN ACCESS EC OPHTHALMOLOGY
Research Article
Vitrectomy in Diabetic Patients with Chronic Kidney Disease and
Diabetic Retinopathy
Fiorella Salvador Salvador1*, Renata García Franco2, Diego Valera Cornejo1, Ximena Mira Lorenzo2, Paulina Ramírez
Neria2, Yolanda Villalpando Gómez2, Miguel Vázquez Membrillo2 and Marlon García Roa2
1Retina Fellow, Mexican Institute of Ophthalmology, Queretaro, Mexico
2Retina Service, Mexican Institute of Ophthalmology, Queretaro, Mexico
Citation: Fiorella Salvador Salvador., et al. “Vitrectomy in Diabetic Patients with Chronic Kidney Disease and Diabetic Retinopathy”. EC
Ophthalmology 10.1 (2019): 43-50.
*Corresponding Author: Fiorella Salvador Salvador, Retina Fellow, Mexican Institute of Ophthalmology, Queretaro, Mexico.
Received: November 28, 2018; Published: January 02, 2019
Abstract
Purpose: To describe the anatomic and functional outcomes in patients with chronic kidney disease who underwent pars plana
vitrectomy for proliferative diabetic retinopathy.
Methods: We retrospectively reviewed the medical records of patients with chronic kidney disease who underwent 25-gauge
vitrectomy for diabetic vitreous hemorrhage and/or tractional retinal detachment between January 2017 and March 2018. Visual
outcome, intraocular pressure and complications were documented.Results: The postoperative refractive error calculated by A-scan
was -0.72 ± 0.96 diopters and that calculated by optic biometry was -0.13 ± 0.83 diopters in patients with age-related macular
degeneration. Higher myopic shifts were observed with A-scan measurements than with optical biometry measurements.
Results: 68 eyes of 57 patients. The median GFR was 19.9 ml/min/1.73m2 (IQR: 7.45 - 41.65). Preoperative best corrected visual




Conclusion: Vitrectomy in patients with chronic kidney disease and diabetic retinopathy can be performed with favorable anatomical
and functional results.
Keywords: Diabetes Mellitus; Proliferative Diabetic Retinopathy; Chronic Kidney Disease; Pars Plana Vitrectomy’ Best Corrected Visual
Acuity
Abbreviations
DM: Diabetes Mellitus; CKD: Chronic Kidney Disease; ADA: American Diabetes Association; DR: Diabetic Retinopathy; GFR: Glomerular

Acuity; IOP: Intraocular Pressure; SD: Standard Deviation; IQR: Interquartile Range; PVCH: Postoperative Vitreous Cavity Hemorrhage;

Introduction

(42

44
Citation: Fiorella Salvador Salvador., et al. “Vitrectomy in Diabetic Patients with Chronic Kidney Disease and Diabetic Retinopathy”. EC
Ophthalmology 10.1 (2019): 43-50.
Vitrectomy in Diabetic Patients with Chronic Kidney Disease and Diabetic Retinopathy
      

et al.
been demonstrated that a more rapid rate of loss of kidney function was associated with an increased risk of adverse clinical outcomes

Diabetic retinopathy (DR) is the main cause of vision loss in working-age adults. In 2010, out of an estimated 285 million people with
dia


dia
Proliferative diabetic retinopathy such as vitreous hemorrhage and/or tractional retinal detachment can be treated successfully with
vitr
and functional outcomes of patients with DR and CKD undergoing pars plana vitrectomy.
Material and Methods
Study design
This was a retrospective, single-arm, cohort study. It was carried out at the Mexican Institute of Ophthalmology in Queretaro,
Mexico. We studied patients with diabetic retinopathy and chronic kidney disease who underwent vitrectomy for proliferative diabetic
retinopathy between January 2017 and March 2018. The study complied with the Declaration of Helsinki. The ethics committee of the
Mexican Institute of Ophthalmology approved this study.
Eligibility and exclusion criteria

alo2 (categories G3a,
          
22
proliferative retinopathy; and follow-up time of less than 6 months.
Subjects, follow up and measure outcome
               
ophthalmological history (previous surgeries and laser treatment), use of preoperative intravitreal injection of anti-vascular endothelial
growth factor (VEGF) agents as adjuvant therapy (3 to 5 days before surgery), and ophthalmological examination including best corrected

fundoscopy.
In addition, we obtained data from surgery such as type of surgery performed (25-gauge pars plana vitrectomy with or without
cataract surgery), operated eye, use of intraocular tamponade, complications and use of injection of intravitreal anti-VEGF agent. Among
the postoperative data, we collected data from ophthalmological examination and complications at 1, 30, 90 and 180 days after surgery.
Surgery procedure
The procedure was carried out using the Constellation Vision System (Alcon Laboratories, Fort Worth, Texas, USA) in all the cases.
Citation: Fiorella Salvador Salvador., et al. “Vitrectomy in Diabetic Patients with Chronic Kidney Disease and Diabetic Retinopathy”. EC
Ophthalmology 10.1 (2019): 43-50.
Vitrectomy in Diabetic Patients with Chronic Kidney Disease and Diabetic Retinopathy
           
bu
               
membrane was kept intact. All patients underwent a standard 3-port 25-gauge pars plana vitrectomy. Pan-retinal photocoagulation

and corticosteroids eye drops were initially applied 4 times a day, with the number of applications gradually reduced when intraocular

Statistical analysis
A database was created in the Microsoft Excel 2010 program. A descriptive statistical analysis was carried out using the Stata 14
statistical package. Qualitative variables are shown as percentages and simple frequencies. Quantitative variables are presented as means
with standard deviations (SD) or medians with interquartile ranges (IQR), according to the normality of the variable evaluated by the
Shapiro-Wilk test.
Results
68 eyes of 57 patients were included. The preoperative clinical characteristics are summarized in table 1. The median GFR in general
was 19.9 ml/min/1.73m2 (IQR: 7.45 - 41.65). The median GFRs in the 3a, 3b, 4 and 5 categories were 50 ml/min/1.73m2 (IQR: 46.65 -
55.4), 31.50 ml/min/1.73m2 (IQR: 31- 37.7), 20 ml/min/1.73m2 (IQR: 18.8 - 22) and 6.55 ml/min/1.73m2 (IQR: 7.2 - 8.2), respectively.

Figure 1: Distribution of the sample according to GFR in KDIGO categories.
GFR: Glomerular Filtration Rate. G3a, G3b, G4, G5: Categories of GFR according Kidney Disease Improving Global Outcome
(KDIGO) guidelines.
Characteristics Patients (n = 57)
Age (mean ± SD), years 54.51 ± 9.98
Sex, n (%)
Male 
Female 
Comorbidities, n (%)
SAH 
Dyslipidemia 
Heart disease 
Hyperuricemia 
Table 1: Preoperative clinical characteristics of the sample.
SD: Standard Deviation; SAH: Systemic Arterial Hypertension.
45
Citation: Fiorella Salvador Salvador., et al. “Vitrectomy in Diabetic Patients with Chronic Kidney Disease and Diabetic Retinopathy”. EC
Ophthalmology 10.1 (2019): 43-50.
46
Vitrectomy in Diabetic Patients with Chronic Kidney Disease and Diabetic Retinopathy
                
dia   
shown in table 2.
G3a G3b G4 G5
    
    
 - - - 
  - 
Total, 16 11 13 28
Table 2: Distribution of treatment according to CKD’s categories.
G3a, G3b, G4 and G5: Glomerular filtration rate according Kidney Disease Improving Global Outcome (KDIGO)
guidelines.

laser photocoagulation.
Characteristics related to surgery are shown in table 3.
Characteristics Eyes (n = 68)

Right 
Left 

25-gauge PPV 
25-gauge PPV with cataract surgery 
 
 

Silicon oil 5000 cSt 
Air 
 
Table 3: Characteristics related to surgery.
PPV: Pars Plana Vitrectomy; VEGF: Vascular Endothelial Growth Factor; cSt: Centistokes; SF6: Sulfur
Hexafluoride.

eye
Citation: Fiorella Salvador Salvador., et al. “Vitrectomy in Diabetic Patients with Chronic Kidney Disease and Diabetic Retinopathy”. EC
Ophthalmology 10.1 (2019): 43-50.
Vitrectomy in Diabetic Patients with Chronic Kidney Disease and Diabetic Retinopathy
47
Figure 2: Postoperative BCVA related to preoperative BCVA.
BVCA: Best corrected visual acuity.

ret       
        


eye
 
we

Figure 3: Retinal fundus photographs of two patients included in the study. A: Right eye with proliferative diabetic retinopathy
before surgery. B: Same patient in case in A six months after surgery (air as tamponade). C: Right eye with proliferative
diabetic retinopathy before surgery. D: Same patient in case in C six months after surgery (silicon oil as tamponade).
Citation: Fiorella Salvador Salvador., et al. “Vitrectomy in Diabetic Patients with Chronic Kidney Disease and Diabetic Retinopathy”. EC
Ophthalmology 10.1 (2019): 43-50.
Vitrectomy in Diabetic Patients with Chronic Kidney Disease and Diabetic Retinopathy
48
Discussion
Chronic kidney disease and diabetic retinopathy continue to be important causes of morbidity in our population, being both
complications of DM. The long-term administration of heparin anticoagulant drugs during hemodialysis increases the risk of vitreous
   


t
any treatment for CKD at the beginning of the study.

car  

et
al. et al.


As well as our results, Su., et al.
The use of preoperative anti-VEGF agent may promote the reduction of neovascularization and decrease the rate of intraoperative
he


receive it. This result can be explained by the selection criteria for the administration of preoperative anti-VEGF, since this was decided
in cases with proliferative diabetic retinopathy with greater complexity (no previous laser treatment, tractional retinal detachment with
active neovascular membranes, rubeosis iridis).
         
int
compartmentalize the eye and may have a role in inhibiting progressive neovascularization in the anterior segment by preventing the
diffusion of angiogenic substances. However, there are few reports about postoperative complications and the use of different internal
tamponades in this group of patients.
Limitations on the Study
There are several limitations on this study due to the retrospective nature of it, for example there are variables that were not controlled,
and
to obtain better results.
Conclusion
It seems that vitrectomy in patients with chronic kidney disease and diabetic retinopathy has favorable anatomical and functional results.


Citation: Fiorella Salvador Salvador., et al. “Vitrectomy in Diabetic Patients with Chronic Kidney Disease and Diabetic Retinopathy”. EC
Ophthalmology 10.1 (2019): 43-50.
Vitrectomy in Diabetic Patients with Chronic Kidney Disease and Diabetic Retinopathy
49
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Volume 10 Issue 1 January 2019
© All rights reserved by Fiorella Salvador Salvador., et al.
... 8 Two groups were compared to see the outcome. According to some authors the use of anti VEGF agents there is no role in the outcome of vitrectomy in PDR cases 9 . In our study not only the active bleed, risk of resurgery was also reduced, hence anti VEGF agents are safe and effective in favourable outcome. ...
Article
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Purpose: To estimate the prevalence of blindness, visual impairment, diabetes mellitus, and diabetic retinopathy in patients aged 50 years and older in the State of Nuevo León, Mexico. Methods: Ninety-one clusters of 60 people aged 50+ were selected randomly and a rapid assessment of avoidable blindness (RAAB) was conducted. Participants had their visual acuity and cause of visual impairment assessed, underwent a random glucose test and fundoscopy under mydriasis if they had diabetes. The diabetic retinopathy (DR) degree was classified according to the Scottish diabetic retinopathy grading scheme. Results: From the sample 5,055 (92.6%) people were examined. The blindness prevalence was 1.7% (95% Confidence Interval: 1.3–2.1%). Cataract (32.6%), DR (29.1%) and glaucoma (16.3%) were the leading causes of blindness. The prevalence of severe, moderate, and early visual impairment was 1.0%, 5.1%, and 7.7%, respectively. Among respondents, 31% had diabetes and 8.1% of them was not diagnosed prior to the study. Of all participants with diabetes, 50% had glucose levels of 200 mg/dl or higher and 15.7% had sight-threatening diabetic retinopathy. Conclusions: Besides strengthening of cataract intervention activities, more ophthalmic services for diabetic retinopathy and glaucoma control are needed in Nuevo León to provide timely intervention to prevent blindness.
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Background: The recent advancement in the management of chronic renal failure (CRF) has significantly increased the longevity of the patients, which increase the incidence of severe vitreoretinopathy. The vitrectomy is highly risky in this particular group of patients due to their systemic comorbidity. The timing surgical intervention is usually delayed because of the systemic conditions. This study is to evaluate the safety and effectiveness of 25-guage vitrectomy for severe vitreoretinopathy in the CRF patients. Methods: In this retrospective study, 16 eyes of 16 CRF patients with severe vitreoretinopathy were undergone 25-guage vitrectomy in the department of Ophthalmology of the Second Hospital of Tianjin Medical University from February 2015 to April 2017. The visual outcome, complications and perioperative medical management were documented and analyzed. Results: The best-corrected visual acuity(BCVA)of fourteen eyes were lower than 20/200 preoperatively. Surgery duration ranged from 28 to 72 min, with a mean of 48.4 ± 13.6 min. During the surgery, 12 eyes were diagnosed with DR, while two them were complicated with tractional retinal detachment and one with branch retinal vein occlusion. Three eyes were diagnosed with branch retinal vein occlusion, and one eye was diagnosed with hypertensive retinopathy. Postoperative BCVA of six eyes ≥20/40, seven eyes ≥20/200, and three eyes < 20/200. BCVA of eight eyes improved more than three lines, three eyes improved two lines, and four eyes improved one line. BCVA decreased from hand movement to light perception in one patient who developed neovascular glaucoma two weeks after surgery. Conclusion: In chronic renal failure patients with severe vitreoretinopathy, the well-planned minimally invasive vitrectomy is effective and safe. Additionally, careful management of the perioperative systemic conditions is important to improve the visual acuity and quality of life as well.
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Diabetic retinopathy (DR) is a leading cause of vision-loss globally. Of an estimated 285 million people with diabetes mellitus worldwide, approximately one third have signs of DR and of these, a further one third of DR is vision-threatening DR, including diabetic macular edema (DME). The identification of established modifiable risk factors for DR such as hyperglycemia and hypertension has provided the basis for risk factor control in preventing onset and progression of DR. Additional research investigating novel risk factors has improved our understanding of multiple biological pathways involved in the pathogenesis of DR and DME, especially those involved in inflammation and oxidative stress. Variations in DR prevalence between populations have also sparked interest in genetic studies to identify loci associated with disease susceptibility. In this review, major trends in the prevalence, incidence, progression and regression of DR and DME are explored, and gaps in literature identified. Established and novel risk factors are also extensively reviewed with a focus on landmark studies and updates from the recent literature.
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Diabetic retinopathy, an oculardisease, is governed by systemic as well as local ocular factors. These include primarily chronic levels of blood glucose. Individuals with chronically elevated blood glucose levels have substantially more, and more severe, retinopathy than those with lower blood glucose levels. The relationship of blood glucose to retinopathy is continuous, with no threshold although individuals with hemoglobin A1c levels (a measure of chronic glycemia) <6.5%, generally develop little or no retinopathy. Blood pressure levels have been claimed to influence retinopathy development and progression, but multiple controlled clinical trials of antihypertensive agents in diabetic subjects have produced only weak evidence of benefit from blood pressure lowering on the incidence and progression of diabetic retinopathy. Elevated blood lipids seem to play a role in the progression of retinopathy, and two trials of fenofibrate, a lipid-lowering agent that has not proved effective in preventing cardiovascular disease, have shown benefit in preventing retinopathy progression. The mechanism of this effect may not, however, be directly related to the reduction in blood lipids. Finally, there is strong, but only circumstantial, evidence for a genetic or epigenetic influence on the pathogenesis of diabetic retinopathy. Despite the power of large-scale epidemiologic studies and modern molecular biological and computational techniques, the gene or genes, which predispose or protect against the development and progression of diabetic retinopathy remain elusive.
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Objective: Intravitreal Bevacizumab (Avastin, Genentech Inc., San Francisco, CA) (IVB) has been shown to cause regression of neovessels in proliferative diabetic retinopathy due to its anti-angiogenic effects. This study was performed to investigate the role of Avastin as an adjunct to the management of patients with proliferative diabetic retinopathy undergoing pars plana vitrectomy. Methodology: Fifty four eyes of 54 patients with proliferative diabetic retinopathy scheduled for surgery were included in the study. They were randomized to vitrectomy with preoperative IVB (group one) or standard vitrectomy (group 2). Group one underwent a single intravitreal injection of bevacizumab 1.25 mg /0.05ml one week prior to vitrectomy. Main outcome measures were best corrected visual acuity (BCVA) after surgery, post-operative complications. Results: Mean age of the patients was 52.07±5.54 years (range 39-67). At 6 months, 20 patients in group one had BCVA better than baseline as compared to 12 patients in group 2. In group one, only one patient had early post-operative vitreous hemorrhage, whereas 11 patients in group two had early vitreous hemorrhage. Conclusion: Preoperative IVB is helpful in improving BCVA post operatively, reducing the time of surgery, decreasing the incidence of intraoperative and postoperative bleeding and reducing the frequency of rubeosis and hyphaema.
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Introduction: Since the year 2000, IDF has been measuring the prevalence of diabetes nationally, regionally and globally. Aim: To produce estimates of the global burden of diabetes and its impact for 2017 and projections for 2045. Methods: A systematic literature review was conducted to identify published studies on the prevalence of diabetes, impaired glucose tolerance and hyperglycaemia in pregnancy in the period from 1990 to 2016. The highest quality studies on diabetes prevalence were selected for each country. A logistic regression model was used to generate age-specific prevalence estimates or each country. Estimates for countries without data were extrapolated from similar countries. Results: It was estimated that in 2017 there are 451 million (age 18-99 years) people with diabetes worldwide. These figures were expected to increase to 693 million) by 2045. It was estimated that almost half of all people (49.7%) living with diabetes are undiagnosed. Moreover, there was an estimated 374 million people with impaired glucose tolerance (IGT) and it was projected that almost 21.3 million live births to women were affected by some form of hyperglycaemia in pregnancy. In 2017, approximately 5 million deaths worldwide were attributable to diabetes in the 20-99 years age range. The global healthcare expenditure on people with diabetes was estimated to be USD 850 billion in 2017. Conclusion: The new estimates of diabetes prevalence, deaths attributable to diabetes and healthcare expenditure due to diabetes present a large social, financial and health system burden across the world.
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