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Original Investigation | Journal Club

The Royal College of Ophthalmologists’ National Ophthalmology Database Study of Vitreoretinal Surgery Report 6, Diabetic Vitrectomy

Timothy L. Jackson, PhD, FRCOphth1; Robert L. Johnston, FRCOphth2,3; Paul H. J. Donachie, MSc2,3; Tom H. Williamson, MD, FRCOphth4; John M. Sparrow, DPhil, FRCOphth2,5; David H. W. Steel, FRCOphth6,7
[+] Author Affiliations
1Department of Ophthalmology, King’s College London, King’s College Hospital, London, England
2Royal College of Ophthalmologists’ National Ophthalmology Database, London, England
3Gloucestershire Hospitals National Health Service (NHS) Foundation Trust, Cheltenham, England
4Guy’s and St Thomas’ NHS Foundation Trust, London, England
5Bristol Eye Hospital, Bristol, England
6Sunderland Eye Infirmary, Sunderland, England
7Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, England
JAMA Ophthalmol. 2016;134(1):79-85. doi:10.1001/jamaophthalmol.2015.4587.
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Importance  Patients and clinicians need to accurately assess the risks and benefits of pars plana vitrectomy for proliferative diabetic retinopathy, but clinical trial data may not reflect real-world experience.

Objective  To prospectively audit the complications of vitrectomy for proliferative diabetic retinopathy and help establish benchmarks.

Design, Setting, and Participants  Royal College of Ophthalmologists’ National Ophthalmology Database study of 939 eyes of 834 patients undergoing primary vitrectomy for proliferative diabetic retinopathy at 16 different vitreoretinal units in the United Kingdom. Data were obtained for the period from January 2001 to November 2010.

Interventions  Pars plana vitrectomy with or without delamination/segmentation.

Main Outcomes and Measures  Descriptions of the primary procedures performed, intraoperative complication rate, and proportion of eyes undergoing further surgery. An exploratory analysis of visual outcome was undertaken, with visual success and visual loss defined as a gain or reduction of 0.3 logMAR or more, respectively (approximately 2 Snellen lines), 6 to 12 months after surgery.

Results  Of 420 eyes (among 408 patients) that underwent vitrectomy without delamination, the intraoperative complication rate was 13.1% (95% CI, 10.2%-16.7% [55 of 420 eyes]), with 126 eyes (30.0%) requiring an intravitreal tamponade and 49 eyes (11.7%) undergoing further vitrectomy (median follow-up, 6.9 months); 17.9% of 127 phakic eyes developed cataracts within a year, with 63.6% achieving visual success and 8.2% visual loss. Of 519 eyes (among 463 patients) that underwent vitrectomy with delamination, the intraoperative complication rate was 30.4% (95% CI, 26.6%-34.5% [158 of 519 eyes]), with 299 eyes (57.6%) requiring an intravitreal tamponade and 78 eyes (15.0%) undergoing further vitrectomy (median follow-up, 7.1 months); 21.2% of 126 phakic eyes developed cataracts within a year, with 62.8% achieving visual success and 14.9% visual loss.

Conclusions and Relevance  Diabetic vitrectomy has an appreciable complication rate, particularly if delamination or segmentation are required. Nonetheless, the data available on visual acuity suggest that a majority of patients achieve clinically meaningful gains in vision.

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Figure 1.
Rates of Postvitrectomy Cataract Surgery

Kaplan-Meier curves of postvitrectomy cataract surgery, with cataract surgery modeled as the failure event. PPV indicates pars plana vitrectomy.

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Figure 2.
Visual Acuity in Eyes That Underwent Pars Plana Vitrectomy Without Delamination

Box plots of logMAR visual acuity before and after surgery. The horizontal line in the middle of each box indicates the median, while the top and bottom borders of the box mark the 75th and 25th percentiles, respectively. The whiskers above and below the box mark the 90th and 10th percentiles, respectively. The numbers in parentheses refer to the numbers of eyes with visual acuity at the level shown on the y-axis, for that time period (shown on the x-axis). The points beyond the whiskers are outliers beyond the 90th percentile. CF indicates counting fingers; HM, hand motions; LP, light perception; and NLP, no light perception.

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Figure 3.
Visual Acuity in Eyes That Underwent Pars Plana Vitrectomy With Delamination

Box plots of logMAR visual acuity before and after surgery. The horizontal line in the middle of each box indicates the median, while the top and bottom borders of the box mark the 75th and 25th percentiles, respectively. The whiskers above and below the box mark the 90th and 10th percentiles, respectively. The points beyond the whiskers are outliers beyond the 90th percentile. The numbers in parentheses refer to the numbers of eyes with visual acuity at the level shown on the y-axis, for that time period (shown on the x-axis). CF indicates counting fingers; HM, hand motions; LP, light perception; and NLP, no light perception.

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