Summary:
In patients with proliferative diabetic retinopathy (PDR) complicated by non-resolving vitreous hemorrhage and tractional retinal detachment, pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling significantly reduced the incidence of epiretinal membrane (ERM) formation and decreased the need for repeat anti-VEGF injections compared to PPV without ILM peeling, though it was associated with no significant changes in visual acuity or central macular thickness.
| PICO | Description |
|---|---|
| Population | Patients (n = 57) with proliferative diabetic retinopathy (PDR) presenting non-clearing vitreous hemorrhage and tractional retinal detachment. |
| Intervention | Pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling (n = 26). |
| Comparison | Pars plana vitrectomy (PPV) without ILM peeling (n = 31). |
| Outcome | ILM peeling led to a lower rate of postoperative ERM formation (11.5% vs. 51.6%, p = 0.004) and reduced need for anti-VEGF re-injections (7.7% vs. 35.5%, p = 0.030). Visual acuity improved in both groups without significant differences (p = 0.846). No differences in central macular thickness, FAZ area, or vessel density were observed. |
Clinical Context
Proliferative diabetic retinopathy (PDR) remains a leading cause of vision loss in working-age adults, often complicated by vitreous hemorrhage and tractional retinal detachment. While pars plana vitrectomy serves as the cornerstone surgical intervention for advanced PDR, postoperative complications like epiretinal membrane formation can compromise outcomes. The internal limiting membrane (ILM), the basement membrane of retinal Müller cells, has been implicated in ERM pathogenesis. However, routine ILM peeling during diabetic vitrectomy remains controversial due to concerns about potential risks versus benefits. This randomized trial addressed whether adjunctive ILM peeling during PPV for PDR could reduce postoperative complications without compromising visual outcomes. Understanding the role of ILM peeling in PDR surgery has important implications for surgical planning and patient counseling, particularly in cases with persistent vitreous hemorrhage and traction complications.
Clinical Pearls
- ERM Prevention: ILM peeling during diabetic vitrectomy dramatically reduces postoperative epiretinal membrane formation (11.5% vs. 51.6%), potentially avoiding the need for future surgical intervention.
- Anti-VEGF Burden: Patients undergoing ILM peeling required significantly fewer repeat anti-VEGF injections for diabetic macular edema (7.7% vs. 35.5%), reducing treatment burden and costs.
- Visual Outcomes: Despite preventing ERM formation, ILM peeling doesn’t improve final visual acuity outcomes compared to standard vitrectomy, suggesting prevention of complications rather than enhanced recovery.
- Surgical Timing: Consider ILM peeling particularly in eyes with tractional retinal detachment or high risk of membrane formation, where the benefit-risk ratio favors prophylactic removal.
Practical Application
For vitreoretinal surgeons managing PDR with non-clearing vitreous hemorrhage or tractional retinal detachment, this evidence supports incorporating ILM peeling as part of the surgical plan. The technique appears most valuable in preventing postoperative complications rather than enhancing immediate visual recovery. Clinicians should counsel patients that while ILM peeling reduces the likelihood of needing additional surgery or anti-VEGF injections, it won’t necessarily improve their final vision beyond standard vitrectomy. The 6-month follow-up data suggests the protective effect against ERM is sustained. Preoperatively, assess for iatrogenic tear risk factors, as ERM formation correlates with surgical complications. In younger patients or those with extensive membrane formation during surgery, the benefits of prophylactic ILM peeling likely outweigh theoretical concerns about Müller cell damage.
Broader Evidence Context
This study aligns with accumulating evidence supporting selective ILM peeling in diabetic vitrectomy. Previous retrospective series have suggested reduced ERM rates with ILM removal, though randomized data have been limited. The finding that ILM peeling doesn’t improve visual acuity is consistent with other diabetic surgery studies, which show ERM prevention doesn’t necessarily translate to better vision outcomes. The correlation between ERM formation and both iatrogenic tears and tractional retinal detachment suggests mechanical factors drive membrane development. Interestingly, the lack of difference in macular thickness, FAZ area, or vessel density indicates ILM peeling doesn’t adversely affect macular perfusion or anatomy, addressing a longstanding theoretical concern.
Study Limitations
- Relatively small sample size (n=57) limits statistical power for detecting subtle differences in visual outcomes and rare complications.
- Single-center study from Egypt may limit generalizability to different populations, surgical techniques, or healthcare settings.
- Six-month follow-up may be insufficient to detect long-term effects of ILM removal on retinal function or late ERM formation.
- Study doesn’t report specific ILM peeling techniques or dye usage, which may influence outcomes and reproducibility.
- Exclusion criteria and randomization details not fully detailed, potentially affecting internal validity.
Bottom Line
For patients with proliferative diabetic retinopathy requiring vitrectomy for vitreous hemorrhage and tractional complications, adjunctive ILM peeling significantly reduces postoperative epiretinal membrane formation and the need for repeat anti-VEGF therapy without compromising visual outcomes. While not enhancing vision recovery, ILM peeling appears to be a safe prophylactic measure that reduces future surgical burden, particularly in high-risk cases.
Source: Omar Abdelkarem Hasan, et al. “Outcome of pars plana vitrectomy with and without internal limiting membrane peeling in proliferative diabetic retinopathy.” International Ophthalmology. Read article here.
