Strategy for the management of diabetic macular edema: the European vitreo-retinal society macular edema study.

OBJECTIVE: To compare the efficacy of different therapies in the treatment of diabetic macular edema (DME). DESIGN: Nonrandomized, multicenter clinical study. PARTICIPANTS: 86 retina specialists from 29 countries provided clinical information on 2,603 patients with macular edema including 870 patients with DME. METHODS: Reported data included the type and number of treatment(s) performed, the pre- and posttreatment visual acuities, and other clinical findings. The results were analyzed by the French INSEE (National Institute of Statistics and Economic Studies). MAIN OUTCOME MEASURES: Mean change of visual acuity and mean number of treatments performed. RESULTS: The change in visual acuity over time in response to each treatment was plotted in second order polynomial regression trend lines. Intravitreal triamcinolone monotherapy resulted in some improvement in vision. Treatment with threshold or subthreshold grid laser also resulted in minimal vision gain. Anti-VEGF therapy resulted in more significant visual improvement. Treatment with pars plana vitrectomy and internal limiting membrane (ILM) peeling alone resulted in an improvement in vision greater than that observed with anti-VEGF injection alone. In our DME study, treatment with vitrectomy and ILM peeling alone resulted in the better visual improvement compared to other therapies.

Endoscopic evaluation and dissection of the anterior vitreous base.

The specific concept of pathological anterior vitreous base (AVB) and of its endoscopy-assisted dissection was elaborated during our 20 years' experience with endoscopy for observing the 'in vivo' anatomy and pathoanatomy of the AVB, and for dissecting the anterior vitreous cortex in over 2,000 consecutive eyes. Endoscopy provides a 360° view of the entire vitreous cavity akin to the surgeon's eye being inside the operated eye. Evaluation of the capsulozonular complex, ciliary body, and AVB is not only independent of anterior media transparency, but unimpeded by scleral depression and magnified. High magnification dissection of the AVB gel can be conducted in an individualized and unmatched fashion.

An endoscopic overview of the anterior vitreous base in retinal detachment and anterior proliferative vitreoretinopathy.

PURPOSE: Anterior proliferative vitreoretinopathy (PVR) is an important cause of persistent or recurrent retinal detachment (RD). Endoscopy provides 360° panoramic viewing of the vitreous cavity and high-magnification viewing of the anterior vitreous base (AVB). This study describes the 'in vivo' anatomy and pathoanatomy of the AVB using an ocular endoscope in RD and anterior PVR. METHODS: An intraoperative analysis of over 2000 consecutive eyes undergoing vitrectomy for RD operated with endoscopy-assisted vitrectomy was performed. It was recorded in notes dictated during surgery and in standardized operative reports. Around 1500 surgical videotapes, with the exclusion of diabetic retinopathy and trauma, selected by reviewing the OR reports and notes were retrospectively reviewed. RESULTS: Seven endoscopic criteria associated with anterior PVR complicating RD are described: 'en bloc' stiff anterior vitreous retraction, ciliary detachment, seeding of the AVB by abundant pigmented and/or white granulations, anterior tissue displacement, stiff 'wrinkling' at the vitreoretinal juncture, persistent shallow ciliary/RD under perfluorocarbon liquids and traction-related retinal surface haemorrhages. Causes responsible for failure of conventional vitrectomy for RD are highlighted. Findings in case of hypotony and cyclitic membranes are described. CONCLUSIONS: Endoscopy is a significant adjunct to our understanding of the development of anterior loop traction by obviating the two constitutive parts of the AVB, anterior and posterior, their interconnections and their respective connections to the anterior segment and to the retina. It provides a unique evaluation and thorough eradication of the anterior vitreous cortex as a scaffold for anterior PVR. It might be an adjunct to the prevention of anterior PVR.

Proliferation of the ciliary epithelium with retinal neuronal and photoreceptor cell differentiation in human eyes with retinal detachment and proliferative vitreoretinopathy.

BACKGROUND: There is some in vitro evidence that the adult ciliary body might harbor an inactive population of stem/retinal progenitor cells (RPC), or that ciliary epithelial (CE) cells might have the capacity to trans-differentiate, which may result in a balance between neural and epithelial properties. We have reported alterations in the ciliary body (CB) and adjacent vitreous in vivo by endoscopic evaluation of human eyes with a history of retinal detachment (RD) and anterior proliferative vitreoretinopathy (PVR). METHODS: The present study examined with light microscopy three paraffin-embedded phthisic human eyes with RD and anterior PVR. One normal eye, exenterated for an orbital tumor, served as the control. All specimens were stained with hematoxilin and eosin safran (HES), and serial sections were immunostained with antibodies against EGFR, Ki67, CD133, NSE, rhodopsin, and GFAP. RESULTS: We observed: (1) an intense proliferation and displacement of clusters of CE cells into the vitreous base in a "neurosphere-like" fashion; (2) differentiation of CE cells towards early and late neuronal [photoreceptor (PR)] lineages; and (3) strong staining of EGF and EGFR in the CE. Such proliferation, migration, and differentiation were not present in the CE of the control eye. GFAP staining was intensely positive in the three detached retinae, and was negative in the CE of eyes with RD, as well as in the retina of the control eye. CONCLUSIONS: Our observations suggest that EGFR-positive CE cells in the adult human eye in vivo with RD and PVR form "neurosphere-like" structures; their differentiation seems to be directed towards the neural and photoreceptor lineage, and not towards glial formation. In the adult human eye, the CE in a pathological retinal environment such as RD might provide a spontaneous source of donor cells for retinal transplantation.