Ординатура / Офтальмология / Английские материалы / Diabetes and Ocular Disease Past, Present, and Future Therapies 2nd edition_Scott, Flynn, Smiddy_2009
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114 Diabetes and Ocular Disease
Figure 6.20. Vitreous infusion suction cutter (VISC) with surrounding fiber optics inserted through the pars plana into the vitreous cavity.
Dr. Machemer performed the first pars plana vitrectomy in 1970 and soon realized the potential value of removing not only opaque vitreous hemorrhages but also proliferative membranes, and repairing retinal detachments by releasing vitreous traction [57]. This new surgery provided a way to restore sight for people who had become blind from diabetic retinopathy.
At this early stage, the vitrectomy instruments evolved rapidly with a single hand-held instrument named the vitreous infusion suction cutter (VISC) (Fig. 6.20) providing vitreous infusion, suction, and cutting. The advantages of having a second instrument in the vitreous cavity for additional infusion, diathermy, tissue retraction, aspiration, etc. were soon recognized and bimanual surgical techniques and additional instruments were developed [58].
The initial vitrectomies were performed with just coaxial light from the operating microscope, but intraocular visualization was soon improved by the introduction of fiber-optic light sources into the vitreous cavity.
O’Malley [59,60] emphasized the value of decreasing the diameter of the instrument used in the eye by separating the functions and introducing the guillotine type cutter and 3-port system separating the suction-cutter from the infusion and the fiber-optic light source (Fig. 6.21). Aaberg [61–63], Charles (Fig. 6.22) [64,65], Douvas [66], Federman [67], Kloti [68,69], McCuen [70], Michels (Fig. 6.23) [71–79], Peyman [80], Tolentino [81,82], and many others [83–86] expanded and clarified the indications for vitrectomy and made important contributions to instrumentation and surgical techniques. Recently, the size of vitrectomy instruments has been further reduced to 25 gauge [87]; their use decreases postoperative morbidity and recovery time in selected cases.
Improvements in evaluating eyes with opaque media by ultrasound dramatically increased the success of pars plana vitreous surgery. Coleman and coworkers
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Figure 6.21. Early version of Ocutome vitrectomy instrument developed by O’Malley and Heintz, which utilized a back and forth guillotine cutting action of formed vitreous and proliferative tissue aspirated into the side of the instrument tip.
[88,89], and others, developed and refined ultrasound procedures to identify areas of vitreoretinal traction, and the presence, location, and extent of retinal detachments, better.
The use of pars plana vitreous surgery spread rapidly because of its potential to dramatically restore functioning vision for patients who had lost their sight most frequently from complications of diabetic retinopathy, and because of a philosophy of openly sharing experiences and ideas by Dr. Machemer and others involved with the development of pars plana vitreous surgery.
Figure 6.22. Steven T. Charles, M.D., Director of Charles Eye Institute of Memphis, Tennessee. Dr. Charles made many contributions to the development of vitreous surgical instruments and developed numerous creative procedures for vitreous surgery.
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Figure 6.23. Ronald G. Michels, M.D., Professor of Ophthalmology at the Johns Hopkins University School of Medicine, former Director of Wilmer Ophthalmological Institute Vitreoretinal Surgery Service, and Co-Director of The Retina Center in Baltimore, Maryland. Dr. Michels made invaluable contributions to the development of pars plana vitreous surgery by developing new vitreous surgery procedures and publishing extensively on vitreous surgery.
Still, questions remained about when to recommend vitreous surgery for dense nonclearing vitreous hemorrhages, and for eyes with functioning vision but very extensive neovascular proliferation beyond what could reasonably be treated with photocoagulation. Once again, the NEI provided funding for a large multicenter clinical trial named the Diabetic Retinopathy Vitrectomy Study (DRVS) [90], with Dr. Matthew Davis as Director. The DRVS confirmed the benefits of pars plana vitrectomy in removing dense vitreous hemorrhages and extensive neovascularization caused by diabetic retinopathy.
CONCLUSION
The history of the treatment for diabetic retinopathy encompasses almost 60 years and continues to evolve with new innovations. It is composed of many important observations, creative new concepts, elaborate laboratory and clinical research projects, development and refi nement of revolutionary instruments and procedures, sophisticated evaluations confirming the benefits of good control of blood sugar levels, and appropriate photocoagulation and vitreous surgery. A very large number of people have made important contributions to the current level of knowledge and treatment abilities, and the future is even more encouraging for additional discoveries that will further enhance the ability to preserve and regain vision for people with diabetes.
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7
Photography, Angiography, and
Ultrasonography in Diabetic
Retinopathy
ANDREW LAM, MD,
NICHOLAS G. ANDERSON, MD,
CARL D. REGILLO, MD,
AND GARY C. BROWN, MD, MBA
CORE MESSAGES
•Fundus photography plays an important role in monitoring progression of diabetic retinopathy.
•Fundus photography is becoming a popular method of screening large populations for diabetic retinopathy.
•Fluorescein angiography is useful to identify areas of nonperfusion, increased vascular permeability, and neovascularization.
•Fluorescein angiography is useful to guide laser treatment of clinically significant macular edema.
•Ultrasound is useful when media opacity obscures visualization of the fundus and often helps determine appropriate timing of surgical intervention.
Fundus photography, fluorescein angiography, and ultrasonography are valuable tools in the management of diabetic retinopathy. These modalities enable clinicians to document pathology, monitor progression, and guide treatment of this increasingly prevalent disease. In this chapter, the indications and clinical
utility of these tests in the management of diabetic retinopathy will be reviewed.
FUNDUS PHOTOGRAPHY
Background. In 1886, Jackman and Webster published the first report of a retinal photograph taken of a living human [1]. An albo-carbon light source provided illumination for their 2.5 min exposure. While the quality of this first image was limited, by the early 20th century, Fredrick Dimmer had produced photographs of sufficient quality to be incorporated into the first photographic atlas of
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