Lecture: Lessons Learned in Diabetic Retinopathy

>> Hello, I am Maria Berrocal. It is my pleasure to be here to give you this talk on lessons learned in diabetic retinopathy. And these are my financial disclosures. So, the first question is: What is the primary treatment for proliferative diabetic retinopathy? A, PRP laser, B, anti-VEGF injections, or C, vitrectomy? Very good. For all those of you who answered pan retinal photocoagulation, that is correct. Okay. We’ll go to the next question which is diabetic patients with a total vitreous detachment have more disease progression? True or false?
Okay. This is actually false. Having the vitreous separate actually protects patients from disease progression. But we’ll go through all of that in my talk. Next is patients that miss appointments have more complications when they have been treated with laser than with anti-ve FWC a agents? True or false?
It is false. The patients that are lost to follow-up when they have only been treated with anti-VEGF can get severe complications compared to laser. Okay. So, we will discuss a lot of these things going forward. So, let’s talk a little bit about diabetes. We know that diabetes is the modern plague because the prevalence has tripled in a decade in many developing countries. The US has 34 million people with diabetes and half of the US adult population is pre or diabetic. And diabetic retinopathy is the leading cause of blindness among working age people. And this is a huge healthcare burden because a quarter of all US healthcare dollars are spent in treating complications of diabetes. So, here we can see the high cost of diabetes. This is in the US. But it’s, you know, very similar, actually, in many parts of the world.
So, what do we know? We know that 60% of all diabetes will develop proliferative diabetic retinopathy. 50% of these will experience severe visual loss. And laser reduces the risk of severe visual loss to 4%. So, laser has always been proven to be a great treatment to prevent vision loss in patients with diabetic retinopathy. Despite PRP, 5% of patients will require a vitrectomy.
So, what are the principles of diabetic surgery techniques? We have to remove the anteroposterior traction. And we do membrane delamination with manual piccs, sometimes by manual techniques as you can see in this video. Really, what happens in diabetes is that the vitreous jell, the neovascularization, which is caused by the ischemia grows into the back part of the vitreous gel. And then when the gel, the vitreous, starts separating with aging changes, it pulls on those vessels that are part of the retina and it causes traction detachments. So, having a vitreous detachment is protective because it prevents these vessels from growing into the vitreous. So, once you have a vitreous detachment. A complete vitreous detachment, you will not get a traction retinal detachment from diabetes. So, in the past, we were doing PRP, which is still the standard treatment for proliferative diabetic retinopathy, and it works great. But, you know, it doesn’t cure everyone. In the past we had 20 page instrumentation, and we were doing it based on the diabetic vitrectomy study. It was only after they had a vitreous hemorrhage that was not cleared for a long time. Doing macular off detachments. The visualization were very bad, we didn’t have trocar cannula and couldn’t control the pressure. And hemorrhaging during the surgeries was a problem. And we needed a lot of instruments going in and out. And this was an old movie of mine done with 20-gauge. And you can see how the whole part of the retina and the vitreous came out of the sclerotomy and you would have a lot of complications that we don’t see any more with better instrumentation. This is another old movie of mine done in 20 gauge. We use scissors a lot. We had a lot of difficulty controlling bleeding and the instruments were very large compared to, you know, the tissue that we were trying to remove as can be seen in this movie. Vitrectomy probes, we had a large opening, as can be seen here. And you can see we were cutting on the surface of the retina and then as we were doing that, the retina would jump at the opening of the vitrector. And we would cause breaks as we can see here in here. But now we have much better instrumentation. We have smaller gauge surgery, which is very useful in diabetes. We have wide angle viewing systems. We have better fluidics and interocular pressure control with the machines. And we have high speed cutters which cut, you know, 20,000 and even 30,000 cuts per minute. Which makes for a little movement in the retina. We have improved microscopes. 3D viewing systems. We have pharmacologic adjuvants that we can use before surgery like anti-VEGFs. And it is possible to remove the hyaloid completely, which is what we have to do because the hyaloid, the vitreous gel, the hyaloid is the enemy in diabetic patients. So, the biggest study that we had in the past was the DRVS. This is a study from 1985. Diabetic retinopathy vitrectomy study. It was a very large study followed for four years which is good because studies in diabetes, we need long follow-up. This is a lifelong disease. And it was almost a thousand patients. And basically, what we saw in the study, patients were randomized into early vitrectomy or delayed vitrectomy. We saw that in type 1 diabetics, doing vitrectomy earlier, had greater results, and the more severe, the greater the benefit of the vitrectomy. The reason for this was because younger and type 1 diabetics, they will go on to develop tractional retinal detachments because they have a longer time of being diabetic with an attached hyaloid. So, the neovascularization can grow into the hyaloid and cause problems. So, you know, maybe now that we have much better instrumentations, we should be doing vitrectomy earlier in the course of the disease in diabetic patients. So, I’m just gonna show you some of the lessons that I have learned along the years here. And here we can see the attached hyaloid is the enemy. Eyes of diabetic patients with or without a posterior vitreous detachment behave differently. And these are the two eyes of the same person. The left eye is a highly myopic eye that has a vitreous detachment.
You can see there. And you can see that there’s no retinopathy in that eye. But the right eye, despite having laser, the patient has vitreous hemorrhage and has significant disease. Because, again, having a posterior vitreous detachment is protected. And what we actually saw here — I’m sorry. This is a study that was published by Ono in 2005. And what they did is they looked at patients that had a complete vitreous detachment, no vitreous detachment or a partial detachment and they followed them for three years. The patient with the complete PVD had no progression of their retinopathy. Whereas those with the partial, the retina was starting to detach, 100% progressed. And those with no PVD, half progressed. We know that a total vitreous detachment, a PVD, stabilizes these eyes long-term and they don’t have a retinal detachment because they don’t have anything that will pull the retina up and they will not have vitreous progression. But not only does the vitreous detachment prevent you from getting progressive retinal detachment. But also protects against diabetic macular edema. I was treating this patient with anti-VEGF injections. And the edema never went away until the vitreous detached. The vitreous detached in 3/3, the vitreous detaches and after that, all the edema went away without any more injections being needed. So, the vitreous also contributes to diabetic macular edema. And sometimes the patients, the retinopathy can progress very quickly. This is a patient that within two months went from the picture on the left, he was being treated with laser and had a traction, a detachment. The whole gel pulled up and caused the break and detached the retina. This is another patient from the pandemic which was scheduled for surgery on the picture on the left and then was canceled. And in three weeks — just three weeks — had that massive fibrous macular degeneration occur. And here we’re gonna see — sorry. Here we’re gonna see — okay. This movie. We’re gonna see what the hyaloid does. This patient, we are removing — we see here that the hyaloid is attached and we are lifting the hyaloid. This is very important to do in diabetics because that is the scaffold on to which the vessels grow. And, you know, the vitreous pulls on them, causing the detachment. So, after we lift up the hyaloid, we are removing part of the blood. We’re aspirating it from the surface of the retina. And then we continue — you can see all the thickened hyaloid there attached to all the areas of bleeding and the vessels. So, in surgery, it’s very important in diabetics to remove all the attachments of the vitreous to the retina. Because once we remove everything, then we are basically protecting that retina from any progression of disease. And then, you know, checking the periphery is very important. And then applying laser. Laser is really the standard of care and during surgery you can use laser also as diathermy to apply it to bleeding vessels. I use air the end in many I of these cases. It helps me see there’s still areas of the hyaloid. And this one I was doing in 27 gauge because I think smaller gauges are better for severe disease. So, here we have another case. We see that the blood was trapped below the vitreous gel, you see in this eye, the vitreous was partially detached over the posterior pole. That’s where the blood accumulated. I lifted that and I’m aspirating the blood with the vitreous cutter. And once I do that, then I start detaching the red — the rest of the hyaloid that’s still attached to parts of the retina to prevent any progression of disease. Sometimes you have a situation like this. Where you have like a big blood clot still over the fovea. And you can very gently remove that. You have to do that with a lot of care so as not to cause a break. Lesson number 2, not all diabetic patients younger than 50 get progression of cataracts after vitrectomy. This was a patient of mine that I operated 22 years prior. She was a young patient, and they do not get progression of the cataracts. Patients whose cataracts progress with vitrectomy are usually old patients. Older than 50. Who very nuclear sclerosis. And you remove the hyaloid, these eyes stay stable forever. Lesson three. Laser is not a permanent solution in diabetics that have an attached hyaloid. So, you have a patient, a young diabetic, with an attached hyaloid. You laser them. They remain stable for many years. But then with the vitreous starts separating, they can bleed — they can bleed. So, these are patients that we need to follow. And this is a patient of mine, this picture, in 14 months despite having significant PRP, had this fibrovascular proliferation occur on the surface of the retina. Just something that we see. And when we think about protocol S from the DRCR net in 5 years, patients that were treated — most of the patients were fairly young. The mean age was 51. So, we can assume that a lot of patients had an attached hyaloid. So, only half of them require just one full PRP. Many of these patients required either more laser, because half of them developed vitreous hemorrhage besides — despite having laser. And 12% develop a traction retinal detachment. And of these, 19% had to undergo vitrectomy. But even in the one that was treated with anti-VEGF, 2 to 4% developed vascular glaucoma. Lesson four, we know that laser is basically curative if you have a vitreous detachment. But if the vitreous is still attached, you have to watch these patients forever because they can get bleeding and different things. But the lesson four, which is really the most important lesson here, is that anti-VEGF in my mind should never be used as a single treatment for patients that have prolific diabetic retinopathy and don’t have a total PVD. Why is that? Because the anti-VEGF just suppresses VEGF for a period of about a month, maybe two. So, when the patient doesn’t come in for return appointments, they get a surge of VEGF and they develop glaucoma and serious disease. On the bottom was a patient lost to follow-up and came in with that massive iris macular degeneration. And they do worse when treated only with VEGF and not PRP. Eyes that don’t come in for follow-up points, 33% of the ones treated with anti-VEGF that are lost to follow-up just for a year develop traction retinal detachment. Compared to only 2% of those that had been treated with laser. And we know that diabetic patients miss a lot of appointments. More than half are lost to follow-up for more than 6 months and also for more than a year. And here we see another case. This is a patient, the one in the top. 11 days after receiving bevacizumab in the right eye developed the traction retinal detachment. And the bottom, we had patient that had a mild vitreous hemorrhage and developed a traction retinal detachment with bleeding. Lesson five, we should use the smallest gauges we have access to for the most difficult cases. And this, you know, when I started saying this, people thought, you know, it didn’t make any sense. But as you can see in this movie, you can use these instruments. Here I’m just using the vitreous cutter as a forcep to pull tissue up. Then this is 27 gauge and it’s so small that I can get under the tissue and use it as scissors there. I lift it up as I get under the tissue to use the scissors. So, the same cutter can be used, as you can see there, as a forcep pulling the tissue up and a scissors getting under the tissue and cutting the tissue away all with a lot of very, very good control of what is going on in the retina. And then see, we were able to do this. Only 35 minutes have elapsed there. And then we do a lot of laser and this patient stays stable for a long time. So, we can use the vitrectomy probe as a fluid needle, as scissors, as forceps, we can do blunt dissection with it, we can do a lot of things. This is another case that really shows the hyaloid is the problem. This patient had multiple surgeries and was still detached because the hyaloid was still detached to the retina. Here I’m using perfluorocarbon liquid. Because the hyaloid was still attached, it created all these breaks in the periphery. It was almost like a retinal detachment. I used that to detach the retina and applied a lot of laser to the periphery to stabilize this eye. And gas — lesson six — is that gas tamponade is ideal for diabetic patients with tractional retinal detachments. This is a case, I do a lot of combined phaco and vitrectomy. And this patient had a dense cataract. I’m removing the cataract and then had this massive old vitreous hemorrhage which I’m removing. And under that vitreous hemorrhage, we see that the retina is very ischemic and it’s all detached. So, I’m removing membranes that I see and I’m injecting perfluorocarbon liquid to detach the retina to see better what’s happening. And this patient has a lot of ischemia. I remove in the periphery. Very important to do. You don’t want contraction afterwards. So, after I do all that, then I aspirate and really prefer gas to silicon oil in diabetics. And I’m removing the perfluorocarbon liquid and the retina is detached and leaving the gas. This is a year later. And when it’s a one-eyed patient and the patient can’t see, is that it traps the blood in different places and they need another surgery. This is lesson seven. Limited membranectomy. This is a technique that I started using because I have a lot of patients that present like this. They have all that fibrosis and it’s very thick. And the macula under there is attached, but they can’t see because of this vitreous gel that is partially detached, but it’s all opaque and thick. So, what I’m doing in these cases, I know they’re trying to remove everything may — will cause — can cause a lot of breaks and the patients can do very badly once a break occurs. So, here I’m just clearing the center and doing those little incisions towards the periphery. The idea is to remove all the traction in the center so that the patient can see. And I have done this technique for many patients. This one stayed stable for more than five years. This is another patient where you can see the same thing. This is the first patient that I did this in. And I had operated the other eye trying to remove everything and I lost that eye. Here I’m using diathermy to create an opening in the center and clearing the center so that he can see through it. But it’s not enough to clear the center. You have to remove all the vitreous attachments to that big membrane and create some relaxing incisions there so that the contraction doesn’t continue. And this patient stayed stable for over five years looking like that. So, if you remove all the attachments to the vitreous, the retinopathy will not progress. This is another case showing the same thing. You can see by the OCT that all of the fovea is detached by membranes and by traction. So, this is the key. Removing all the vitreous in the periphery that is attached to that big plaque. And then getting under the tissue. And opening it up in areas that are safe. And I’m clearing all of the posterior bowl there as much as I can. You see that the retina in this case is more detached — attached to the hyaloid and there’s multiple layers of membranes. So, I’m going very, very slowly. Doing those little segmentations of the membranes so that the traction will not continue. I get under the membrane. This is all done 27 gauge too. And it’s much better, the smaller gauges, because you can get under those tissue planes and under those membranes. And here I’m using forceps to remove because there’s still a layer of tissue there over the fovea. I’m doing this with the ingenuity 3D system. And you can see how changing the color channels helps us sometimes see these membranes better. So, I’m just dissecting everything very, very slowly. And removing all those attachments around the fovea very, very carefully with 27. And then trimming it off. And once you remove that traction, then those eyes tend to remain stable. But the key is to make sure there’s no vitreous attached to any of that. And then I left air in this eye. I did more laser to the periphery to remove all of the anti-VEGF. And this eye did really well. You can see the fovea’s attached there and remained 20/70 for a long time. Lesson eight, sometimes you get a case like this. Everything is clustered and you don’t know where to enter. Detaching the tissue over the optic nerve a little bit will create an opening. And you can start then the dissection from the inside out. As you can see there, I’m dissecting from the inside and then I start keep dissecting towards the periphery. Very slowly. So, this is a trick for some of these very bad cases where you don’t see an entry point to go through. Digital visualization is really the future. I love digital visualization. You get enhanced depth of focus. It’s ergonomic. This is a case. This is a diabetic case that wasn’t useful because it had a lot of traction towards the periphery which is not really what we normally see. We see this more with sickle cell disease. But I am removing the vitreous in the periphery and what I see there is that there is like some mounds of neurovascularization in the periphery that are pulling the retina and causing a schisis-like contraction. You see it there. I’m removing all that. From the OCT that I did beforehand, I saw a membrane and there was a fovea attached. So, I’m removing that membrane over the fovea. And then I am cauterizing all those vessels that were pulled up and you see that there were schisis and detachment of the retina. Once I remove that, I cauterize really well. It’s important to cauterize as you go along in these cases. Because you don’t want bleeding — a lot of blood to get in your way of your visualization. So, then I’m applying laser all around. And I’m doing a fluid-air exchange so that I can flatten the retina under air and apply lazier to all of those edges of the retina that were there. And I’m aspirating. And then I’m gonna apply laser to everything and this is how it looks still with a partial gas bubble. This is another case. A very young diabetic, 28 years old. This was her only eye. And she had a very dense hemorrhage. You had old hemorrhage, which looks white, and fresh hemorrhage which looks red. Very, very hemorrhagic eye. So, after I remove everything, I’m aspirating all the blood from the surface. I’m doing this 27-gauge too. I’m blowing — using reflux to blow some of the blood out. And then I’m getting under the tissue to lift it up a little bit so that I can start all that dissection. And I’m doing that. And then aspirating all of that. All of that tissue. Segmenting it. You see how it was in traction and you bounced back. And very, very slowly removing everything. Trying to control the bleeding as best as possible. Here is over the optic nerve where we still have tissue. And we still have that plaque over the posterior pole. But very slowly using the aspiration of the probe to lift the tissue and see what’s underneath. And you can see how nicely the tissue comes towards the vitrectomy probe without jumping into it and we can peel the tissue and cut the tissue from vessels without causing breaks. So, it gives you a lot more control when we’re doing this with the 27-gauge. And, you know, this patient attained 20/40 vision. Short follow-up is really meaningless in younger diabetics, because younger diabetics are gonna be diabetics for many years. They’re not always gonna be perfectly controlled. Whenever we do a study, we need to have long follow-up on these patients. A lot of things happen. Just to say I did a surgery and he was fine a month later doesn’t mean anything. You have to follow them for a long time. This was a patient that I showed before that progressed very, very quickly. And as you can see, caused a traction a retinals detachment. The retina is floppy. It’s important when you have breaks to mark them with diathermy. So, you can see them under air. And this is where the patient looked many years later. This is an older case of mine. I used too far a lot of this viscodissection. This is injecting viscoelastic, acid, under the membrane to separate it. It’s still a technique I use sometimes in very, very bad cases. You see with the probe we get between the tissue and the retina. And we inject a viscoelastic and it does sort of like a blunt dissection of it. So, that then it allows us to remove the tissue better. This was a case that I was doing 23 gauge. So, nowadays I would probably do a lot of these maneuvers just with the vitrectomy probe. But it’s a good technique to keep in the back of your mind. Because viscoelastic will help you in some of these difficult cases that you think are sometimes inoperable. It will help you be able to fix them. So, then after I’m done with everything, you can either leave that tuft there or remove it. I’m removing them with the same vitrectomy probe with suction. So, here I’m doing the same maneuver — oh, sorry. Here I’m doing the same maneuver, but I’m doing it with — I’m doing with the cutter. So, I’m doing the same thing that I would have done with the viscoelastic, but I just use the same cutter to get under the tissue, move sideways and blunt dissect and lift it up a little bit so that I can remove it. So, this is the same technique as with the viscoelastic. But just with the vitrectomy probe. This is a case — a very bad case — the whole retina was detached. It was very difficult, you know, it was very hemorrhagic. Difficult to see. So, here I’m using chandelier illumination and using bimanual technique using the probe scissors and forceps in the other eye to remove some of that tissue. The case on top is a case that I thought I wasn’t gonna be able to fix it. But having a lot of patience and very slowly removing all that very — very adherent fibrovascular tissue, I was able to remove everything and this patient maintained 20/70 vision like you see there in the bottom for many years. Sometimes we need to do combined phaco and vit in some cases. This is a patient that had a significant cataract as you can see there. Sometimes when I have a vitreous hemorrhage, you don’t get a red reflex. So, using the light eye to illuminate the anterior chamber as you’re doing this is very, very helpful. And this is the case that I have showed you before that had the old blood. Other things outside the box that will be useful is using intraoperative fluorescein. This is something that I use in some cases like this. This is a case that had a dense vitreous hemorrhage. And after I removed the hemorrhage, I’m injecting fluorescein dye with some filters in the operating room so that I can see what areas cause the bleeding and areas of ischemia so that I can treat them better with laser. Every time that I do a vitrectomy in a diabetic, I apply a lot of laser to the periphery and all the areas of ischemia to stabilize these eyes long-term. And we can see here that we can see the areas where you have neovascular vessels and where the dye is coming out from. And this is very useful, because if you laser those eyes really — those areas really well — you will prevent postoperative bleeding. This is one of the main complications of doing diabetics. So, here we can see all the areas that are oozing fluid so that we can laser them. Here you are gonna see the same thing. This is actually a dislocated IOL on a diabetic. And I did a fluorescein on this patient too. And what we saw was that this patient had a lot of ischemia and a lot of cystoid macular edema in the fovea. So, we removed this IOL. We placed another three-piece IOL. But at the end you can see how much cystoid macular edema this patient had. So, this was a useful thing to have in your things. This was a 60-year-old who was a double amputation patient. Had bled significantly and kept bleeding. So, when I — after I removed the blood, I did a fluorescein on him just to see what — where the main areas of neovascularization, and I can see that there’s some superiorly. And those areas inferiorly. And this is sometimes useful because then you know exactly where you need to apply more laser. It wasn’t so much on the areas of hemorrhage, but those other small areas there that we’re seeing. So, this is just a useful adjunct to have in your things to do during surgery. You can see all those — all those areas there that are very, very active neovascularization. Despite this patient having had laser and having had anti-VEGF injections. Lesson 12, I think we are probably doing vitrectomy too late in most patients. We shouldn’t wait until a patient looks like that in the right to do a vitrectomy. This is a patient that progressed very quickly, in eight weeks, to what we saw on the right. So, when we see a patient with very bad disease doing vitrectomy sooner is a lot easier. Doing vitrectomy on the picture on the left is a lot easier than doing it on the picture on the right. And maybe we should be using vitrectomy more as a way to prevent traction retinal detachment in patients that have an attached hyaloid. In younger patients. In type 1 patients that have severe disease. The removal of the vitreous is easier. Once we remove the hyaloid, we prevent any progression of the disease, macular edema, traction retinal detachments and others. That is patient of mine 12 years post vitrectomy and this patient maintained 20/30 vision. I decided years ago to look at my data. And what I did is I looked at all the eyes that I had done vitrectomy in the worse eye, you know? Because when you see a patient, you do the vitrectomy in the worse eye when they see you. And see what happened over time. See what happened in real life. And I had at least eight year follow-up on all of them. I had a long follow-up. Patients younger than 50 years of age and patients older than 50 years of age. Because most patients younger than 50 still have the hyaloid attached. Whereas older patients tend to have the hyaloid detached. And what I saw was that two times in eyes in the eyes that had what ended up happening was that the worse eye that I did vitrectomy earlier ended up being the eye with the better vision. Even though the other eye — the non-vitrectomized eye was better initially. So, in eyes that did not have a vitrectomy that were younger than 50 years of age, five times more eyes ended up with visual acuity worse than when they did not get earlier vitrectomy. Compared to the eye that was vitrectomized. And these eyes even required many more procedures because they needed more anti-VEGF, more surgeries, education. 27.8 times more procedures were required. And eyes that were worse at the beginning but had a vitrectomy, 2.6 times more eyes improved visual acuity. So, what we saw is that even though we did surgery in eyes that were much worse, and had either traction detachment or dense vitreous hemorrhage, those eyes ended up being the better eye later. So, vitrectomy is really protective to many of these eyes. And this is a case with proliferative diabetic retinopathy that I am doing early vitrectomy. This patient has so the areas of neovascularization. Had bled. So, I am injecting triamcinolone to be able to see the vitreous well, removing all of the vitreous. And then I’m applying laser photocoagulation all around. We don’t have to do it super-heavy very close to the arcades, you know? We can just treat a lot of the areas of ischemia. And this stabilizes eyes, you know, basically forever. We know that maybe early vitrectomy could be a panacea for diabetes with an attached hyaloid. We know that laser or anti-VEGF can be effective in many eyes, particularly if they have a total vitreous detachment. But eyes with an attached hyaloid will always continue to progress. And even eyes that have been stable for decades, once they start developing a posterior vitreous detachment, they can still get bleeding and detachment. We know that compliance is a big problem in young diabetics. They have difficulty coming in. They have, you know, they have jobs to keep. They have children to take care of. So, PRP is very, very effective in these eyes. But we still need to follow them. And vitrectomized eyes do remain stable forever. So, whenever we’re thinking of an eye, we see a patient, we have to think of the status of the hyaloid. Because it’s two different diseases. A diabetic eye where the vitreous is detached, will progress very little. Whereas a diabetic eye where the hyaloid is still attached will progress. We’ve had worse progression of the disease and can develop traction retinal detachment. So, every time you see an eye, think of the status of the hyaloid. Lesson 13, we have to think of the whole patient. You know, the eye is just are reflection of what’s going on in the body. So, we also know that not only diabetes, but obesity and diabetes having tripled in many, many countries. We have a lot of patients that are overweight or obese and that’s why they have diabetes. And we know that obesity increases the risk of both type 1 and type 2 diabetes. And that gastric bypass surgery can reserve diabetes in type 2 obese diabetics. And we know that obesity, what fat cells do, lymphocytes, produce inflammatory cytokines that are in patients with diabetic retinopathy. Having these patients lose weight is very, very protective for the eye because it reduces inflammation by a lot of other pathways. And many diabetic patients are not only VEGF-driven. VEGF may not be the main player. It can be the inflammatory cytokines. And lesson 14, your loyalty is always to the patient. You have to give them the best treatment based on the status of the vitreous and the patient’s circumstances. If a patient cannot come for appointments or comes from very far away, photocoagulation really will stabilize most eyes. 90-some percent of eyes. But, you know, if they have significant severe disease, maybe offer them earlier vitrectomy, especially if they’re young, because that stabilizes eyes forever. So, really, the status of the vitreous is the most important thing when you’re looking at a diabetic. And, you know, we have to take care of all the patients. Even the poor patients, the patients that cannot come to follow-up, the patients that live far away, the patients that don’t have any money. We have to treat them too. That’s why we all became doctors. And, you know, I was very lucky to be trained by wonderful people who showed me a lot of things. Like — and provided us with per fluorocarbon gases like Dr. Chen and Dr. Lincoff. Dr. Chan, silicone oil, wide angle viewing systems, ways to treat diabetic detachments, Dr. Harry Flynn and viscodissection and multi-function instruments. We have to remember all of those who have contributed so much to our memory. Going back to the poll questions. We know that the primary treatment for proliferative diabetic retinopathy is laser treatment. Do not treat these patients only with injections. Because if they’re not following up, you can lose a lot of those eyes. But if they are type 1 diabetics with a detached hyaloid you can offer them vitrectomy. But I always do laser before vitrectomy because I think the results are better. Poll question number two, diabetic patients with a total vitreous detachment have more disease progression. No. The vitreous detachment is protective for diabetic eyes. And poll number three, patients that miss appointments have more complications when they’re treated with laser than with anti-VEGF? No, they have more complications when they’re treated only with anti-VEGF because the anti-VEGF only works for a very small period of time. And then they get a rebound effect of excess anti-VEGF which can give neurovascular glaucoma or detach the retina. Thank you very much for your attention. And now I will answer any questions that you may have. I see that I have questions here. Let’s see. The first question is having the vitreous completely detached after a process of a TRV will relieve complications of traction which have already occurred? Okay. So, if you have a traction retinal detachment, okay? And if you had a patient that had a traction retinal detachment and you do a vitrectomy and you remove all of the vitreous attachments, you will not continue to get more traction or traction detachments. You’re relieving all the traction. So, that will not progress. That will be curative. I hope that answered your question. And then the next one is: How impact of diabetic retinopathy can be reduced in diabetic type 2 chronic elderly patients? Okay. Well, if you have an elder patient that already has a vitreous detachment, for example, doing a lot of laser. Laser is really curative for these patients. I would do a good photocoagulation of these patients and you will stabilize them. This is particularly important in very elderly patient who is may be wheelchair, may be bedridden, cannot come to appointments. So, laser is really key here, treatment. Okay. What is the reason diabetes have a high number of loss to follow-up? Well, diabetes tend to be younger. I mean, they have bad disease because they’re not taking really good care of their diabetes, right? So, their compliance is not that great. So, they’re younger patients. They have jobs. They cannot miss their job. They may lose their job if they don’t go, you know, if they miss a day of work to go to your appointments, they have to take care of their children, you know? Elderly patients that are retired have more free time to come to appointments. I think that is the reason. Okay. So, why is gas preferable to heavy liquids? Okay. It’s not that it’s preferable to heavy liquids, because heavy liquids, we only use them during the surgery. But gas is preferable to silicone oil in diabetic patients. Why is that? Because when we put silicone oil, one, we need another surgery to remove the silicone oil. That’s one reason. And although the patient can see through the oil and they cannot see through the gas, if they bleed, it stays localized. So, if they bleed in the fovea, it stay there is like a clot, you know? The oil keeps it — the blood localized. And they can get membranes there. If they have gas, the gas presses on the retina better. It has a more buoyant force. And then after the gas goes away, if they still — you have a fluid-filled eye. So, if they re-bleed, you can do a fluid-air exchange. And I have a movie in EyeTube showing exactly how to do that in the office. Which is really, really useful. Because if you have a diabetic that has a vitrectomy and they re-bled, you can take care of that in the office. So, the movie is there. Here we have would you remove a retinal membrane with a significant edema not responding to intravitreal injections? Yes, this they have traction or a thick membrane and don’t respond to intravitreal injections, you can remove the membrane. I do that sometimes. What I do in these eyes, if they don’t respond to anti-VEGF, I put triamcinolone in the eye or something else, and they sometimes respond to it better. And the next is it seems contradictive with the philosophy of removing all hyaloid, what is the explanation? We are removing all of the hyaloid attachments to this tissue. Removing all of the hyaloid first. But the tracks of hyaloid tissue that are very, very adherent, that would be very difficult to remove without causing breaks, you have to in your mind think about what do you want to accomplish? In these cases, it was just traction detachment. We remove all the vitreous adhesions to the plaque so there’s no more traction occurring afterwards, right? And then we’re clearing the area over the fovea and we’re doing these circumferential — these radial cuts in the membranes so that we don’t get any centrifugal traction and that really relieves all the traction. We are removing all of the hyaloid attachments to this, yes. New tips for managing massive intraoperative bleed something when should silicone oil be used what is the timing for its removal? So, if we have massive intraoperative bleeding during the surgery, what we want to do is put the pressure all the way up. As I’m doing this surgery and it starts bleeding, I’m very careful cauterizing everything so that the eye doesn’t get all full of blood. But if I have massive intraoperative bleeding, what you can do is you can just leave gas in the eye and then come back in a week and re-operate that eye, you know, when the clots have dissolved. And when — if I have a one-eyed patient or if I have a patient where I created a lot of breaks, I may want to use silicone oil. And then I try to remove them about two to three months afterwards. Let’s see. How to identify hyaloid membrane when examining patient at the slit lamp. Well, in the slit lamp, you see a ring, you know that the hyaloid has been detached. That is the easiest way to be able to tell that at this point. And you can also use the OCT. Do the OCT cuts over the optic nerve and you’ll be able to see that there. Will you take into account the vision before deciding to do an early vitrectomy in an eye with lots of intraocular fibrosis? Yes. So, if a patient is — if they have a lot of intraocular fibrosis and it’s very, very vascular, and the fovea is attached and they’re seeing well, I may not do early vitrectomy in these cases because, you know, the chances of me creating a break, I will just watch them. And then as soon as, you know, if I see that the macula starts to be threatened, then I would do surgery. In these cases like that I try to stabilize them by applying laser away from the fibrous tissue. You don’t want a laser on top or very close to fibrous tissue because then you can have contraction of the tissue, from the heat. For chronic macular — is there any — or repair? So, I use okay anti-VEGF within five days of the time that I’m going to do the surgery. If it looks very vascular. You know? If the fibrotic tissues, like some of the ones that I showed, white and no vessels, I don’t think anti-VEGF is a help there. It’s not going to suppress any vessels. But if it’s red and you have angry vessels, then injection it. But don’t do it a month ahead. Because you can get progression of the detachment and get a worse situation. You can get a detachment from that. What do you think of fibrous and diabetic retinopathy. I think that’s very good questions and they have been shown to be protective. To be very good in helping with diabetic retinopathy. So, it’s a cheap alternative to treat patients. And it’s also protective for their heart. So, yes. We know that it decreases the progression of retinopathy. So, yes, they’re a very good option. Okay. So, this one — in diabetic macular edema, how many doses of anti-VEGF are recommended? And how much time? So, when I have diabetic macular edema and I’m treating with anti-VEGF, I treat monthly until I see a reduction. If after three or four I don’t see any change whatsoever, I may add a steroid. I may do triamcinolone. Because some patients, especially if they have a lot of inflammation, very obese, more inflammatory cytokines may respond better to steroids and combine the two. Next one, 45-year-old male, P — okay. So, if the vitreous hemorrhage is very clear, you can wait for it to clear and add more laser and put more anti-VEGF there and add more laser. But if it’s very dense, definitely vitrectomy. What has been in the JAMA a study saying that laser is leading to complications — okay. Okay. So, no. I — laser does not give you more complications or lead to more vitrectomies. There was — there was a study that compared anti-VEGF and vitrectomy. And what it showed was that many of the patients had faster, you know, visual recovery with vitrectomy. But laser does not really cause significant complications. When they compared laser anti-VEGFs in protocol S, the loss of visual field was similar. Because these patients get loss of visual field because they have ischemia in the periphery which is the area that you’re treating. So, no — laser prevents — you’re still gonna have patients that despite treating them with laser they’re gonna bleed or have severe disease and you need a vitrectomy. But laser stabilizes more eyes. It reduces — 5% of patients treated with full PRPs will still require vitrectomy. Those are the statistics. Are we seeing more neovascular glaucoma nowadays? Yes, yes. Definitely. As I said before, the standard treatment, the standard of care, the number one treatment for a patient with proliferative diabetic retinopathy is PRP. Anti-VEGFs — PRP works forever. The suppression of the VEGF is forever. Anti-VEGFs suppress, you get a rebound and that’s why you’re seeing more neovascular glaucoma. You’re protect. A PRP as a primary therapy causing ischemia to decrease the — no. PRP does not really cause ischemia to the retina. The PRP, you’re treating the areas of ischemic retina so, this is decreasing the amount of VEGF that the eye is producing. So, it acts in the same way as an anti-VEGF. It will not decrease the efficiency of anti-VEGF as a second line treatment. Apart from the status of PVD, what are the reasons for significant difference in the DR grade of both eyes of the patient? Yes. Usually it is — it can be two things. If you have a PVD in one eye, you will have very mild disease, or no disease at all. And if you don’t have a PVD in the other eye, you will have more severe disease as I showed in all the studies. But also, when you see a patient like that, check the carotids. You may have an obstruction in one carotid and not in the other. That’s a reason to do an ultrasound of all the carotids. To identify breaks when you’re doing a break, you see fluid in an area. You know a break is there. Always mark with diathermy. When you go under, you may not see it and you need to treat them afterwards. Well, high myopia is protective because they get a vitreous detachment sooner. It’s because of the vitreous detachment, not because of the high myopia. For a PDR covering the — yes. I will do that if you have a pre-macular bleed do surgery soon. Because otherwise what’s gonna happen is you can get fibrosis from the blood there. Is there any merit in researching drugs by intravitreal injection to cause PVD. Well, we tried that. We tried that — they tried this with — and it was not effective. Yet. But yes. It would be great if we could have a drug that would safely cause a PVD. Yes. It would be curative for a lot of diabetics. That’s what we were hoping for it, but it did not turn out that way. What is your opinion on leaving silicone in the eye long-term? Okay. Yes. If you have a case that you operated, detached, you had to operate them again and you think that taking the silicone oil out is gonna help reattach. Yes, in some cases you have to leave the silicone oil forever. And exchange the silicone if it emulsifies and put new in. I’ve seen a case of re-detachment, what is the ideal time? Well, there’s no ideal time to prevent that. When I removed the silicone oil, from the silicone oil study, we know that 25% of eyes when you remove silicone oil will re-detach. So, what you do is you remove — when you remove the silicone oil, I always check for areas of traction and I apply more laser. I may leave some air in. Those are sort of the things that I do. When I remove, I see there’s a lot of breaks and a lot of pathology, I may put oil back in. Anti-VEGF and steroids together? That’s for cases with edema. Maybe anti-VEGF, maybe three weeks later, steroids. I never ILM peel with diabetic vitrectomy. Most have cysts can and it can cause a hole. Is it recommended to do cataract extraction — yes. If I have a severe diabetic retinopathy, I try to do laser first. But if you can’t see hardly in because of the cataract, you can do a combined cataract and vitrectomy. Remove the cataract and in the same procedure, remove the vitreous and do a lot of laser. Can — citicholine be visible for diabetic retinopathy? I really don’t know. What is your experience of using the check indication — okay. Yes. Ocriplasmin is not helpful in reducing a PVD. That’s why nobody is using it anymore hardly. Because even in cases where you just had an area of macular attraction, it wouldn’t really — it wouldn’t really help. So, I wish I it worked, but it doesn’t. So, anyway, thank you so much for your attention. I hope this has been helpful. You will have my — you’ll have my email that I put there so any time you have a really bad case and you want to consult something for me, please feel free to do so. I will try and help in any way I can. So, thank you very much.