SURVEY OF OPHTHALMOLOGY VOLUME 43 • NUMBER 6 • MAY–JUNE 1999

DIAGNOSTIC AND SURGICAL TECHNIQUES

PETER HERSH AND MARCO ZARBIN, EDITORS

Vitrectomy in the Management of

Diabetic Retinopathy
WILLIAM E. SMIDDY, MD, AND HARRY W. FLYNN, JR, MD

Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami School of Medicine, Miami, FL, USA

Abstract. According to the Early Treatment Diabetic Retinopathy Study, at least 5% of eyes receiving
optimal medical treatment will still have progressive retinopathy that requires laser treatment and pars
plana vitrectomy. During the past decade, improvements in instrumentation and surgical techniques
have allowed more difficult cases of diabetic retinopathy to be candidates for vitrectomy. However,
although the thresholds for performing surgery within established indicated situations have been low-
ered, only a few additional indications have been established. Although vitrectomy improves the prog-
nosis for a favorable visual outcome, preventive measures, such as improved control of glucose levels
and timely application of panretinal photocoagulation, produce better results. The authors review the
indications, techniques, and results of vitrectomy in the management of diabetic retinopathy. (Surv
Ophthalmol 43:491–507, 1999. © 1999 by Elsevier Science Inc. All rights reserved.)

Key words. diabetic retinopathy • media opacities • panretinal photocoagulation •

vitrectomy • vitreoretinal traction

Prospective clinical trial results have defined the
management of diabetic retinopathy. Population
screening is the most efficient strategy to preserve vi-
sion, as complications of diabetic retinopathy that
are detected early may be treated to yield the highest
chance of preventing more severe retinopathy.11,15,117
Prevention of retinopathy or reduction in its rates of
progression via optimal glucose control44,45 and laser
treatment at earlier stages have been advocated and
implemented.117 The mechanisms by which lower glu-
cose levels prevent progressive retinopathy are prob-
ably multifactorial and are beyond the scope of this
review. Similarly, the mechanism by which laser pho-
tocoagulation is effective is not clearly understood,
and its efficacy remains an empiric observation.
Timely application and reapplication (as indi-
cated) of laser photocoagulation is the mainstay of
treatment to reduce visual loss and to avoid the need
for vitrectomy in patients with more advanced com-
plications of diabetic retinopathy.8,50–53,55,83,120,149 Even
in eyes with severe complications, early panretinal
photocoagulation (PRP) may improve subsequent
surgical outcomes.36,59
However, despite preventive regimens and timely
treatment, substantial numbers of eyes will develop
complications of progressive retinopathy and may
become candidates for vitrectomy.2,61 This article will
review the indications, techniques, and results of vit-
rectomy for complications of diabetic retinopathy.
Surgical Indications
The initial indications and surgical rationale for
pars plana vitrectomy in diabetic patients were
largely established by the mid-1980s.1,19,42,47,49,78,94,103,

491
© 1999 by Elsevier Science Inc. 0039-6257/99/$19.00
All rights reserved. PII S0039-6257(99)00036-3
492 Surv Ophthalmol 43 (6) May–June 1999 SMIDDY AND FLYNN

TABLE 1
Indications for Vitrectomy Because of Severe Complications of Diabetic Retinopathy
I. Media opacities
A. Nonclearing hemorrhage
1. Vitreous
2. Subhyaloid, premacular hemorrhage
3. Anterior segment neovascularization with posterior segment opacity
B. Cataract preventing treatment of severe proliferative diabetic retinopathy (lensectomy)
II. Traditional defects
A. Progressive fibrovascular proliferation
B. Traction retinal detachment involving the macula
C. Combined traction and rhegmatogenous retinal detachment
D. Macular edema associated with taut, persistently attached posterior hyaloid
III. Other indications (often after vitrectomy)
A. Vitreous hemorrhage/ghost cell glaucoma
B. Retinal detachment—traction or rhegmatogenous
C. Anterior hyaloidal fibrovascular proliferation
D. Fibrinoid syndrome
E. Epiretinal membrane (nonvascularized)

104,113,124,133
As detailed below, these primarily involve
removal of media opacities and relief of tractional el-
ements from the retinal surface (Table 1). As instru-
mentation and surgical technique have been refined
during the past decade,76 these indications have
been broadened and refined, i.e., the timing of vit-
rectomy has been accelerated as improvements in
surgical instrumentation have produced better vi-
sual acuity outcomes.
MEDIA OPACITIES
Historically, the first indication for para plana vit-
rectomy was severe nonclearing diabetic vitreous
hemorrhage.3,93 Vitreous hemorrhage is probably
the result of traction on the neovascular or fibrovas-
cular complexes from incomplete posterior vitreous
detachment (PVD).40,58,92 As timely application of
PRP has become more widespread, the incidence of
profound visual loss from isolated dense vitreous
hemorrhage has lessened, presumably because less
aggressive cases (those with less extensive neovascu-
larization and fibrovascular proliferation) respond
more frequently to PRP than do cases with more ag-
gressive retinopathy. Concurrently, development of
newer vitrectomy techniques and instrumentation
allows successful outcomes even in more complex
cases. As a result, the distribution of cases undergo-
ing vitrectomy for nonclearing vitreous hemorrhage
in one center decreased from about 70% in 1977 to
about 20% in 1987.3
Initially, vitrectomy was usually deferred for 6 to
12 months to allow for spontaneous clearance of the
vitreous hemorrhage, enabling delivery of stabilizing
PRP. Currently, surgical intervention for nonclear-
ing diabetic vitreous hemorrhage is usually consid-
ered at an earlier time point. Since type 2 diabetics
more commonly have spontaneous resolution of
hemorrhage and slower progression of fibrovascular
proliferation, the usual approach for patients with
type 2 diabetes is to defer surgical intervention
longer than for patients with type 1 diabetes. In con-
trast, vitrectomy is often considered earlier (within a
few weeks) for type 1 diabetic patients, especially if
severe vitreous hemorrhage has shown no sign of
spontaneous clearing.46
Several clinical features influence the recom-
mended timing of vitrectomy for diabetic vitreous
hemorrhage. Earlier surgical intervention is gener-
ally recommended when no previous laser treatment
has been performed, when the fibrovascular prolif-
eration complexes are more extensive and appear
more vascular, when the fellow eye has rapidly pro-
gressive visual loss, or when the fellow eye is blind.
Surgical intervention may be more appropriately de-
ferred, at least temporarily, when there is a complete
PVD, when extensive prior PRP has been delivered,
or when other labile medical conditions coexist. Pa-
tients with sustained hypertension or elevated levels
of glycosylated hemoglobin should have prompt
and appropriate treatment for these systemic condi-
tions. If a decision is made to continue to defer sur-
gery, echographic monitoring may rule out retinal
detachment.
Subsets of vitrectomy indications for vitreous hem-
orrhage are defined by coexisting features. Rubeosis
iridis in an eye with a recent vitreous hemorrhage,
especially when no panretinal photocoagulation has
been applied, constitutes an urgent indication for
intervention. By the time neovascularization involves
the angle, intraocular pressure is often increased
and an aqueous drainage procedure is usually neces-
sary. In selected cases, limbal or pars plana seton
placement may be performed in conjunction with
the vitrectomy.
An extensive subhyaloid macular hemorrhage
constitutes another subset of surgical indications for
VITRECTOMY FOR DIABETIC RETINOPATHY
media opacity (Fig. 1). The confinement of blood in
the subhyaloid space indicates that the posterior hy-
aloid has not fully separated, and remains as a scaf-
fold for progressive fibrovascular proliferation.40,58
Even though the hemorrhage may clear over several
months, ongoing fibrovascular proliferation fre-
quently establishes broad-based zones of increas-
ingly tight vitreoretinal adhesions. Because of the at-
tendant poor visual prognosis after proliferation
advances, surgical intervention should be consid-
ered relatively early in the course (within a few
weeks after onset). While clearing of premacular
hemorrhage is awaited, however, PRP should be ap-
plied in accessible peripheral areas.
An uncommon feature that may be associated
with, and even masked by, vitreous hemorrhage is
subretinal hemorrhage.107 This may occur spontane-
ously despite laser treatment and may severely limit
final visual acuity if the macula is involved. The pre-
sumed mechanism is transretinal extension of hem-
orrhaging from surface neovascularization. Dense
overlying fibrovascular proliferation confined by a
persistently attached posterior hyaloid may facilitate
such misdirection of bleeding.
The degree of cataract may be difficult to assess in
eyes with vitreous hemorrhage. Vitreous hemor-
rhage attenuates the red reflex, causing the lens nu-
cleus to appear more opaque than in eyes without
vitreous hemorrhage. However, lens opacities may
be sufficient to impair not only the patient’s vision,
but also the physician’s ability to diagnose, monitor,
and apply laser to the retina. In such cases, cataract
surgery may be performed either in combination
with vitrectomy or as a two-step procedure. Reports
before endolaser photocoagulation was available
documented a substantial rate of postoperative rube-
osis iridis and generally poor visual outcomes in apha-
kic eyes or in those undergoing lensectomy at the
time of vitrectomy.12,20,22,98,122 Improved extracapsular
Fig. 1. Left: Preoperatively, there is extensive subretinal hemorrhage and visual acuity of 2/200. Right: Postoperative ap-
pearance after vitrectomy with supplementation of panretinal photocoagulation. Visual acuity is 20/40.
493
and phacoemulsification techniques combined with
the ability to deliver intraoperative photocoagula-
tion probably account for improved outcomes re-
ported with simultaneous lensectomy and vitrectomy
in selected cases.17,23,35,81
Two general approaches to combined lens re-
moval and vitrectomy have been reported. In the
first approach, pars plana lensectomy is combined
with vitrectomy maneuvers, and the anterior capsule
(with central capsulotomy) is preserved for posterior
chamber intraocular lens support. With this ap-
proach, the visual acuity has been reported to im-
prove in more than 75% of cases, including about
25% with visual acuity of 20/40 or better.23,35,81 In the
second approach, a standard limbal approach, cata-
ract extraction is performed, with the IOL insertion
into the capsular bag, followed by the vitrectomy. Vi-
sualization of the posterior segment with this ap-
proach was reported to be excellent, but visual acu-
ity outcomes were not as good in one study of 24
cases.17 In this report the discrepancy in visual re-
sults may be accounted for by case selection. Indeed,
modern surgical techniques for cataract extraction
allow successful outcomes even in the face of rubeo-
sis iridis.82
VITREORETINAL TRACTION
The second general class of indications for pars
plana vitrectomy in diabetic patients includes eyes
with preretinal tractional defects; this class now con-
stitutes the majority of patients undergoing vitrec-
tomy for complications of diabetic retinopathy. The
spectrum of tractional involvement includes macu-
lar heterotopia,127 progressive fibrovascular prolif-
eration (FVP) without retinal detachment, traction
retinal detachment, and rhegmatogenous retinal de-
tachment with a retinal break caused by progressive
traction. Frequently, FVP with traction coexists with
494 Surv Ophthalmol 43 (6) May–June 1999 SMIDDY AND FLYNN

media opacities, and a dual set of indications for vit-
rectomy is present (Fig. 2).
Progressive Fibrovascular Proliferation
Progressive fibrovascular proliferation may occur
despite appropriate panretinal photocoagulation,
especially in type 1 diabetics (Fig. 3). Fibrovascular
proliferation may be very extensive and yet cause
only slight visual loss or may be associated with
marked loss of vision and a more guarded prognosis
for visual improvement after vitrectomy. The lack of
a posterior vitreous detachment is an important fac-
tor associated with the visual prognosis in these pa-
tients. If the posterior hyaloid is still attached and
has broad-based vitreoretinal connections, exten-
sive scissors dissection of fibrovascular proliferation
may be required. Surgical relief of traction is accom-
plished with fewer complications when the zone of
vitreoretinal attachment is less extensive, extends less
anteriorly, and is more acute (because adhesions to the
underlying retina are characteristically less tenacious).
Traction Retinal Detachment
Traction retinal detachment is probably the single
most common specific indication for vitrectomy in
patients with progressive FVP (Fig. 4). The patho-
genesis of retinal detachment involves traction by fi-
brovascular tissues on the retina. Because peripheral
or midperipheral traction retinal detachments progress
to involve the macula in only about 15% of cases per
year,34 caution is advised in recommending vitrec-

Fig. 2. Top: Frequently the media opacities and tractional components coexist. In this schematic representation, there is
vitreous hemorrhage admixed with fibrovascular proliferation, which is causing a traction retinal detachment. However,
this may not be clinically evident because the posterior pole is obscured by the media opacities. (Copyright Johns Hopkins
University; published with permission.) Bottom left: Fundus photograph from a patient who presented with visual acuity
of hand motions. Clearly, there is vitreous hemorrhage, but the configuration of the concentrated surface hemorrhage
suggests probable fibrovascular proliferation along the supertemporal arcade. Bottom right: Appearance postoperatively
after vitrectomy with extensive membrane peeling and silicone oil infusion. Visual acuity is 20/400.
VITRECTOMY FOR DIABETIC RETINOPATHY
Fig. 3. Top left: Fibrovascular proliferation typically pro
gresses from neovascularization from the nerve head and
along the arcade with, initially, relatively good visual acu-
ity. This fundus photograph is from a 29-year-old woman
who presented with visual acuity of 20/30. Top right: With
further progression during the next 3 months, the visual
acuity dropped to 20/200 as the fibrovascular prolifera-
tion enveloped the posterior pole. Bottom: After vitrec-
tomy the visual acuity returned to 20/30.
tomy for localized detachments not involving the
macula. Vitrectomy is generally reserved for cases in
which the macula is involved or clearly threatened
by progressive retinal detachment.
As with cases of nonclearing diabetic vitreous
hemorrhage, there are additional factors that influ-
ence the timing of surgical intervention. Patients
with type 1 diabetes in which coexisting media opac-
ities have prevented delivery of adequate panretinal
photocoagulation or patients in whom a rapidly pro-
gressive course ensued in the fellow eye should be
considered for earlier vitrectomy. Chronic macular
detachment leads to thinner, more atrophic retina,
with more extensive and more tightly adherent fi-
brovascular membranes. Consequently, the ana-
tomic and visual prognoses are poorer in such pa-
tients. Therefore, when marked visual loss caused by
macular detachment has been present for 6 months
or more, surgery may not be recommended. Other
risk factors decreasing visual prognosis include mac-
ular detachment, extensive distribution of detach-
ment, and iris neovascularization.72
Combined Traction and Rhegmatogenous
Retinal Detachment
Combined traction and rhegmatogenous retinal
detachment constitutes an indication for diabetic vit-
495
rectomy (Fig. 5). The rhegmatogenous component
is induced by progressive FVP contraction. Pathog-
nomonia of a rhegmatogenous cause is the appear-
ance of hydration lines, with a more mobile, ele-
vated retina. A more sudden and profound visual
loss usually occurs with a rhegmatogenous compo-
nent than with a solely traction detachment. Although
some cases with a rhegmatogenous component may
be only slowly progressive and could be closely mon-
itored without surgery (especially when partially se-
questered by laser scars), prompt surgery is often in-
dicated for most cases. The retinal break usually
occurs posterior to the equator but may escape de-
tection until surgery. Common sites for retinal
breaks include areas adjacent to previous chorioreti-
nal scars, or at the base of vitreoretinal adhesions.
Diabetic Maculopathy
A rare, more subtle traction-induced complication
is macular edema induced by the contraction of a
taut, persistently attached posterior hyaloid. This
subtype of diabetic macular edema does not re-
spond to focal or grid laser photocoagulation. The
vast majority of cases of diabetic macular edema do
not appear to be induced by traction and should be
considered for photocoagulation in accordance with
the results of the Early Treatment Diabetic Retinop-
496 Surv Ophthalmol 43 (6) May–June 1999 SMIDDY AND FLYNN

Fig. 4. Left: Traction retinal detachment in a 54-year-old woman with a preoperative visual acuity of 20/200. Right: Post-
operatively, the visual acuity improved to 20/30.

athy Study.56 Selected cases with a tractional configu-
ration respond to surgical release of the traction.68,87,141
A recent study corroborated previous results but also
emphasized both the rarity of the condition and the
difficulty of accurately assessing such cases during
the preoperative examination.68 Consideration of
surgery is limited to cases with ophthalmoscopically
apparent surface traction that is seen to be caused by
a prominent, thickened posterior hyaloid. Visual
acuity is usually decreased to at least the 20/80 level.
COMPLICATIONS OF PREVIOUS VITRECTOMY
Another class of conditions that may constitute an
indication for vitrectomy is the presence of one or
more complications from a previous vitrectomy. Se-
vere recurrent vitreous hemorrhage (either before
or after vitrectomy) not only constitutes a media
opacity, but may also induce a secondary glaucoma
through a ghost cell mechanism.30,31,65,151 Most cases
with increased intraocular pressure caused by vitre-
ous hemorrhage respond to medical therapy. How-
ever, selected cases with poorly controlled intraocu-
lar pressure despite maximal medical treatment may
respond to repeat vitrectomy by relieving the out-
flow blockage caused by red blood cells.134 In some
cases, a fluid-gas exchange procedure performed in
the office may provide sufficient elimination of
blood,avoiding repeat vitrectomy in the operating
room.18,105 In many cases, however, postoperative vit-
reous hemorrhage severe enough to persist beyond
about 6 weeks is a manifestation of reproliferation,
retinal break formation, or other more severe com-
plications that require reoperation.
Retinal detachment—either traction or rheg-
matogenous—after previous vitrectomy constitutes
another indication for repeat vitrectomy. Such cases

Fig. 5. Left: Fundus photograph from a patient who presented with visual acuity hand motions. With extreme traction,
especially with more broad-based fibrovascular entities, a rhegmatogenous component may develop in the retina. This
leads to more generalized retinal detachment, which may be apparent as rapid onset of decreased vision, extensive retinal
detachment, and hydration lines. Right: Postoperatively, the visual acuity improved to 20/80. The chorioretinal scar at
the retinal break is evident just inferonasal to the fovea.
VITRECTOMY FOR DIABETIC RETINOPATHY
usually have a guarded visual prognosis. Because of
the very poor prognosis, repeat surgery may not be
justified in some cases if the fellow eye has stable and
satisfactory visual function.
An especially difficult condition is progressive an-
terior hyaloid fibrovascular proliferation. Most com-
monly, this occurs in the first few weeks after vitrec-
tomy, but in especially fulminant cases of proliferative
diabetic retinopathy it may occur in the absence of
vitrectomy. The incidence in one study was six of 153
eyes undergoing vitrectomy.86 These cases are usually
managed by lensectomy, extensive anterior vitreous
dissection, and, often, silicone oil infusion, similar to
techniques used for proliferative vitreoretinopathy.88
A rare postvitrectomy complication is the fibrin-
oid syndrome, which involves extensive fibrinous
membrane cross-linking of the vitreous.132 The fi-
brinoid syndrome may represent the response of an
ischemic retina and increased vascular permeability
induced in part by vitrectomy. Minor degrees of
postoperative fibrin formation usually resolve spon-
taneously. Intravitreal infusion of fibrinolytic agents
may have a role in decreasing postoperative fibrin
formation (especially in severe cases).90 When severe
degrees of fibrin formation occur, the use of intraoc-
ular tissue plasminogen activator154 or streptokinase
may dissolve the clot.37 Repeat vitrectomy is considered
in the more severe cases, but the visual prognosis is
poor in these eyes with marked postoperative fibrin.
Surgical Objectives and Techniques
The surgical objectives of vitrectomy for complica-
tions of diabetic retinopathy are numerous and are
usually interrelated (Table 2). The objectives are to
address those complications of diabetic retinopathy
that resulted in visual loss. Specifically, this involves
the removal of axial media opacities and preretinal
traction and the prevention of recurrent complica-
tions, for example, by delivery of appropriate laser
treatment. New instruments and techniques for use
in diabetic vitrectomy have emerged in response to
the need to achieve these objectives more safely and
reproducibly.
TABLE 2
Objectives of Vitrectomy for Severe Diabetic Retinopathy
1. Remove axial opacities
2. Relieve anteroposterior traction
3. Relieve tangential traction
4. Segment or peel epiretinal membranes
5. Effect hemostasis
6. Treat all retinal breaks
7. Deliver laser treatment
a. Limited or full panretinal photocoagulation
b. Local treatment of flat NVE
497
MEDIA OPACITIES
Removal of axial opacities involves the vitrectomy
instrument and, in some cases, lensectomy instru-
ments. Endoillumination, an operating microscope,
and an optical system provide standard visualization
of the vitreous strands and surfaces. Newer instru-
ments now offer a wider choice of cutting rates, suc-
tion pressure, and fragmentation power and mode.
It is essential to completely remove the posterior cor-
tical vitreous during vitrectomy to prevent reprolifer-
ation along the remaining surface. Vitreous removal
typically begins posterior to the lens and progresses
posteriorly so that optimal visibility of the posterior
pole is gained and maintained. The posterior vitreo-
retinal anatomy may then be defined and subse-
quently approached. Special care is necessary to
avoid instrument trauma to the crystalline lens.
Common errors involve reaching too close to the
posterior lens surface to remove blood-containing
retrolenticular vitreous, which may be unusually ad-
herent. Also, nudging or crushing the lens while
reaching across the eye—while either chasing a vitre-
ous skirt with the cutter or attempting to illuminate
vitreous proximal to the cutter sclerotomy—is a
common surgical mistake. It can be avoided by mak-
ing careful, measured movements with segmental
vitreous removal clockwise and counterclockwise
from the cutter sclerotomy while monitoring the
posterior lens surface (aided by a posterior lens
opacity or blood deposited on the posterior cap-
sule). The ora serrata is safely accessible for more
than four clock hours from a sclerotomy if the in-
strument is positioned peripherally.137 The equator
180 away from the sclerotomy is the anterior limit.
VITREORETINAL TRACTION
The elimination of traction involves removal of
anteroposterior and tangential vitreoretinal trac-
tion, as well as removal of membrane-induced sur-
face traction. Several surgical techniques have been
developed to achieve these goals.5,6,33,66,96,100–102,118,153
Segmentation Technique
In the segmentation technique, the traction is se-
quentially dissected by removal of anterior-to-poste-
rior vitreous traction, scissors dissection of bridging
epiretinal traction, and, finally, removal of residual
islands of surface traction (epiretinal membranes
[Fig. 6]).101–102 The vertical scissors are the work-
horse instrument in this technique. Manual or auto-
mated scissors are available. Ideally, the scissors
should be sharp and able to swivel to allow varied di-
rections for progressive cuts. The bottom blade of
the scissors can be used as a pick to define and,
when removed laterally, serve as a blunt dissection
tool. Generally, large segments of fibrovascular tis-
498 Surv Ophthalmol 43 (6) May–June 1999 Fig. 6. The technique
SMIDDY of AND
vitreoretinal
FLYNN
surgery in which (top) first media opaci-
ties and anterior-to-posterior traction
are relieved, followed by relief of bridg-
ing traction, typically with the vitreous
cutter. Vitreoretinal picks and scissors
are used to segment preretinal mem-
brane components (center). The final re-
sult is removal of all posterior segment
traction with remnant stumps of fi-
brovascular proliferation (bottom). Some-
times, the fibrovascular proliferation is
extensive and the posterior hyaloid is
well defined. In such cases, the hyaloid
may be peeled up in a relatively con-
fluent fashion and fewer fibrovascular
stumps ensue. This is more similar to
the delamination technique. (Copyright
Johns Hopkins University; published
with permission).
VITRECTOMY FOR DIABETIC RETINOPATHY
sue may be mobilized, defining underlying feath-
ered attachments to the retina that are subjected to
diathermy and cut, or trimmed to a small stalk and
subjected to diathermy. The direction of dissection
is usually safest from posterior to anterior, as the re-
verse may allow unrecognized, excessive traction on
thinner, more vulnerable peripheral retina. It is crit-
ical to define the plane of dissection early on to facil-
itate a safer and more rapid removal. When the fi-
brovascular anatomy does not present an obvious
cleavage plane, one may usually be developed at the
edge of the optic disk. At times, the posterior hya-
loid may be seen to be shallowly elevated from some
portion of the retina, and incising it with a sharp
needle or blade allows access to the proper dissec-
tion plane. Directly over a region of subhyaloid hem-
orrhage is another convenient site. Fibrovascular at-
tachments may be linearly and inextricably attached
along retinal vessels, in which case broader stumps
must be circumscribed.
Delamination Technique
In the delamination technique, the anterior to
posterior traction is commonly removed first. Hori-
zontal scissors and multifunction instruments (such
as lighted picks or lighted forceps) are used to re-
move the preretinal tissue at the retinal plane as one
or more large pieces (Fig. 7).33,100 In this regard, it is
similar to the en block technique (discussed below),
except that the anteroposterior traction of the vitre-
ous has been previously removed. Complete removal
of the remaining fibrovascular stalk from the optic
nerve head may include some axons, but does not
Fig. 7. The delamination technique. Although it is similar
to the en block technique, the horizontal scissors are more
commonly supplemented by lighted instruments, such as
lighted picks and lighted forceps, to shave the fibrovascu-
lar proliferation from its retinal attachments. The end re-
sult characteristically shows fewer fibrovascular stumps.
499
adversely affect outcomes.118 Removal of fibrovascu-
lar stalks is not correlated with decreased final visual
acuity, even though glial elements have been dem-
onstrated in removed tissue specimens.118
En Bloc Technique
In the en bloc technique, the surface traction is
removed with scissors as a large, confluent piece,
with the anteroposterior vitreous traction used for
countertraction (Fig. 8).37,86,88,132,154 The theoretical
advantage of this technique is that the anteroposte-
rior traction provides countertraction (serving as a
“third hand”), retracting cut tissue from the retinal
surface to facilitate subsequent surface dissection.
The last step is to remove the anteroposterior trac-
tion and vitreous. Initially, there was concern that
this technique was associated with more intraopera-
tive retinal breaks (35% in an early report),153 but as
more experience with the technique is gained, the
rate seems to be equivalent to that of other tech-
niques (20% in more recent series).66 Also, the con-
sequences of a break when the traction has been
more fully relieved are minimal compared to the
consequences of leaving traction unrelieved.
Superficially, each technique seems to represent a
totally different approach, but all achieve the same
objectives, albeit in a different order. In many cases,
the selected surgical technique is customized as a hy-
brid of all three techniques.
Several adjunctive maneuvers have been de-
scribed to facilitate membrane dissection, regardless
of the basic technique. The viscodissection tech-
nique involves injecting viscoelastic material in the
space between the sheet of fibrovascular membranes
and the retina. Advantages include (theoretically)
distributing the forces more broadly and evenly to
lessen retinal break formation, defining fibrovascu-
lar stumps better, and sequestering hemorrhage,
which facilitates the view to complete dissection. Dis-
advantages include the expense of the viscoelastic
and the difficulties associated with optimally tapping
the space. This technique is unnecessary for most
cases, but it is useful for some, especially in those
with thin, atrophic retinas, and particularly if a rheg-
matogenous component to the detachment is
present.
Tissue plasminogen activator has been shown to
dissolve fibrin clots postoperatively, but it has also
been described to allow for more effective mem-
brane dissection when injected intravitreally 15 min-
utes preoperatively.75 Preretinal membranes are
rarely double-layered, but vitreoschisis may give that
illusion.129 It is important to be alert for the finding
of traction-induced retinoschisis, since the inner
layer is best not dissected. The best clue is the abrupt
appearance of a different dissection plane after the
500 Surv Ophthalmol 43 (6) May–June 1999
Fig. 8. The en bloc technique. Initially, a small core vitrectomy is performed. The posterior hyaloid space is entered and,
typically, horizontal scissors are used to dissect the vitreous from the fibrovascular attachment (left). Once this has been ac-
complished, the vitreous cutter is used to remove the remaining vitreous and fibrovascular proliferations in one en block
fashion (right).
actual plane has been transversed for a while. A
newer modality that may be well-suited for cutting
preretinal membranes is the excimer endolaser.73
Currently under investigation and development, this
instrument holds promise, especially for more pe-
ripheral membrane cutting and for retinotomies,
when necessary.
Scleral buckling is sometimes recommended to re-
lieve peripheral retinal traction from such unreachable
or undissectable membranes.67 Usually an encircling
exoplant is combined with peripheral retinocryopexy
or laser, but in selected cases a segmental element may
suffice when the traction is limited to a local region.
Perfluorocarbon liquids are most useful in cases
of large retinal tears to stabilize and reattach the
posterior retina while anterior dissection is com-
pleted, but they also may control or contain intraop-
erative bleeding so that membrane dissection can be
safely completed.85
CONTROL OF HEMORRHAGE AND
REPROLIFERATION
Intraoperative hemostasis facilitates completion of
the other surgical objectives and optimizes the
chance of surgical success by reducing postoperative
fibrin and blood. Intraoperative bleeding seems to
increase as the case proceeds, and is an important
SMIDDY AND FLYNN
contributing factor to an apparent nonlinear in-
crease in complication rates with longer surgery du-
ration cases. Although these are most apparent as
media opacities, a potentially more insidious factor
is that they may contain promoters of cellular prolif-
eration or serve as substratum for proliferation post-
operatively. Strategies include using intravitreal di-
athermy, increasing the intraocular infusion
pressure intraoperatively, or using intraocular throm-
bin.41,146 Diathermy may be combined with other in-
struments, such as scissors or aspirators, either as spe-
cialized, multifunction instruments or via bimanual
diathermy clips. Optimal intraoperative control of
systemic blood pressure lessens intraoperative and
postoperative bleeding. As noted above, perfluorocar-
bon liquids or viscoelastic dissection techniques may
assist in providing hemostasis,85 but are probably
best reserved for the most severe cases.
An important surgical objective is the delivery of
endolaser panretinal photocoagulation. Before 1983,
intraoperative delivery techniques were not reliable.
With the advent of endolaser 32,60,84,89,116 and indirect la-
ser 62,152 ophthalmoscopic delivery systems, this objec-
tive can now be safely achieved. The diode laser has
been developed more recently and allows photoco-
agulation with certain logistic conveniences.126,135
When media opacities or available instrumentation
VITRECTOMY FOR DIABETIC RETINOPATHY
prohibit delivery of laser, or when more peripheral
treatment is desired, panretinal cryopexy110 or tran-
scleral laser treatment is an option.
MANAGEMENT OF VERY SEVERE CONDITIONS
An essential surgical objective is to treat any reti-
nal breaks or retinal detachment. Retinal breaks oc-
cur in up to 20% of diabetic vitrectomy cases and
may lead to retinal detachment if untreated.114 Most
intraoperative breaks can be successfully managed
by performing fluid-gas exchange and applying en-
dolaser photocoagulation. A critical requirement is
relief of surface traction in the vicinity of the break.
The duration of intraocular tamponade necessary is
judged on the basis of the number and size of retinal
breaks, as well as the likelihood of subsequent fi-
brovascular tractional activity. Silicone oil may play a
role in effecting long-term internal tamponade of
multiple retinal breaks, usually in the setting of a re-
operation for recurrent retinal detachment leading
to reproliferation of fibrovascular tissues causing
proliferative vitreoretinopathy.28,69,125,155 Silicone oil
may decrease or compartmentalize postoperative vit-
reous hemorrhage, allowing more rapid visual reha-
bilitation. Thus, it is ideally suited for early visual re-
habilitation of patients with only one functioning eye,
especially after failure of the initial vitrectomy.26,77 It is
not indicated for patients who must travel by air dur-
ing the early postoperative period, as air travel would
be prohibited with long-acting gas tamponade.
Preoperative anterior segment neovascularization
may regress after vitrectomy in eyes receiving sili-
cone oil, possibly via blocking diffusion of a vasopro-
liferative substance, and may constitute an indica-
tion for using silicone oil in selected cases.60
Removal of the lens may allow more complete pe-
ripheral membrane dissection, but this is usually re-
served for reoperations, especially those with ante-
rior hyaloidal fibrovascular proliferation.57 In less
severe cases, it may be desirable to maintain the an-
terior capsule to provide support for a subsequent
posterior chamber intraocular lens; however, gener-
ally it is removed so it will not contribute to postop-
erative pupil-confining synechia or anterior prolifer-
ation. Lensectomy may lead to an increased risk of
postoperative rubeosis, but this rate is reduced after
application of intraoperative PRP.
A final, but concurrent, surgical objective is to
treat present complications and prevent future com-
plications. Endolaser PRP, even if previous treat-
ment has been applied, is usually delivered intra-
operatively to reduce the likelihood of anterior
segment neovascularization, to treat retinal breaks,
and to facilitate retinal reattachment. In the treat-
ment of retinal breaks, endolaser is usually applied
after membrane dissection and fluid-gas exchange
501
have been completed. However, in some cases it is
advisable to begin PRP before fluid-gas exchange,
because the visibility is generally better then. This is
important in pseudophakic eyes, especially when a
silicone intraocular lens is in place. In selected cases,
it may be advisable to initiate PRP before membrane
dissection, because subsequent bleeding after dissec-
tion may limit or hinder laser treatment. Intraopera-
tive PRP has also been reported to reduce rates of
postoperative vitreous hemorrhage.89
INSTRUMENTATION
The earliest vitreous cutter probes combined the
functions of infusion, suction, and cutting. Later
generations of instruments separated these three
tasks and allowed smaller sclerotomies, lowering the
rate of iatrogenic retinal dialysis.
We prefer a “minimalist” approach, whereby the
array of instruments is limited to a few basics (such
as scissors, pick, forceps). However, a host of multi-
function intraocular instruments have been devel-
oped to facilitate achieving the surgical objectives.
In recent years, the light probe has been modified to
allow additional functions, including the illumi-
nated pick or forceps or illuminated endolaser
probe, while preserving a normal-sized sclerotomy.
Also, a fourth sclerotomy for a multiport illumina-
tion system has also been developed, which frees up
the second hand to use a pick or forceps.
Wide-angle viewing systems (AVI, BIOM, Volk)
have been developed to lessen the risk of inducing
unintended traction and retinal breaks in distant ar-
eas.138,139 A variety of iris retractors are available that
improve intraoperative visualization of the posterior
pole.16,43 Usually reserved for pseudophakic or aphakic
patients, these instruments facilitate visibility in pa-
tients with fixed, small pupils.
Outcomes of Vitrectomy
Varying degrees of concomitant vitreoretinal trac-
tion, retinal detachment, capillary nonperfusion,
and macular edema may influence visual acuity out-
comes in patients with diabetic retinopathy. For ex-
ample, a small proportion of cases present with vitre-
ous hemorrhage as the sole cause of visual loss;
concurrent diabetic maculopathy and extensive cap-
illary nonperfusion also usually limit visual acuity.
After traction is relieved, PRP is applied, and retinal
reattachment is maintained for 6 months, the long-
term visual acuity outcomes are stable.24,70,121
MEDIA OPACITIES
The results of vitrectomy for nonclearing diabetic
hemorrhage have been reported and reviewed ex-
tensively (Table 3).3,21,46,48,64,92,93,104,113,119,133,142,143 Vi-
sion improves in 59 to 83% of patients, and a final vi-
502 Surv Ophthalmol 43 (6) May–June 1999 SMIDDY AND FLYNN

TABLE 3
Outcomes of Pars Plana Vitrectomy for Complications of Proliferative Diabetic Retinopathy*
Outcome (%)
Improved Visual Acuity  20/200 No Light Perception
Vitreous hemorrhage 59–83 40–62 5–17
Fibrovascular proliferation 70 70 11
Traction retinal detachment 59–80 21–58 11–19
Combined traction and rhegmatogenous retinal
detachment 32–53 25–36 9–23
21
* Expanded from Blankenship.

sual acuity of 20/200 or better in 40% to 62% has
been reported. The Diabetic Retinopathy Vitrec-
tomy Study demonstrated that early vitrectomy (1 to
4 months after the onset of severe vitreous hemor-
rhage) for type 1 diabetics yields visual acuity out-
comes of 20/40 or better at 2 years in 36% of this
subgroup compared to only 12% with conventional
management (P  0.001).46 The larger differential
in results is postulated to result from the tendency
for type 1 diabetics to have more extensive and ag-
gressive neovascularization at an earlier stage. How-
ever, the rates of no light perception, 5/200 or bet-
ter, and 20/200 or better were similar for both
groups.
Good visual acuity outcomes have been reported
with vitrectomy for subhyaloid hemorrhage.112,115
Nearly all patients with preoperative visual acuity
of 20/100 or worse regained 20/40 or better after
vitrectomy.
Combined cataract removal, vitrectomy, and en-
dolaser has been studied in relatively small series
with the finding that removal of the cataract does
not increase the risk of rubeosis iridis or compro-
mise the anatomic objectives.17,23,35,81
VITREORETINAL TRACTION
The first report of the Diabetic Retinopathy Vit-
rectomy Study showed a very high rate of severe vi-
sual loss associated with the nonsurgical manage-
ment of patients with progressive FVP.54 Indeed,
36% of eyes deteriorated to 5/200 or worse. Those
results justified a prospective study of 370 patients
with severe neovascularization randomized to early
vitrectomy or conventional management (defined as
deferral of vitrectomy for 1 year unless tractional de-
tachment involved the macula). The rate of final vi-
sual acuity greater than or equal to 20/40 was 44%
for the early vitrectomy group compared to 28% in
the conventional group with 4 years’ follow-up (P 
0.05).47 Patients undergoing vitrectomy in the Early
Treatment Diabetic Retinopathy Study had similar
results (Table 4).61 Other investigators have found
that preoperative factors associated with a more fa-
vorable postoperative result include age less than 40
years, preoperative visual acuity greater than or
equal to 5/200, absence of iris neovascularization, and
application of preoperative photocoagulation.42,74
Probably the most important risk factor associated
with a poor visual outcome after vitrectomy is mac-
ula-involving retinal detachment.27 Another risk fac-
tor is failed vitrectomy in the fellow eye.25 One series
of 50 eyes, many with relatively good preoperative vi-
sual acuity, reported that 72% had improvement
and only 10% lost vision after vitrectomy.64 Thus,
when patients are examined with moderate or severe
visual loss (20/40 to 20/80 range) caused by progres-
sive fibrovascular proliferation, vitrectomy should be
considered.48
The visual outcomes of vitrectomy for diabetic,
macula-involving traction retinal detachment are
somewhat worse than for vitreous hemorrhage alone.
Visual improvement of 2 lines or more on the Snellen
chart has been reported in 59% to 80% of cases, but
postoperative visual acuity reaches 20/200 or better
in 21% to 58% (Table 3).1,78,96,99,106,108,123,143,145,147
The visual outcomes of vitrectomy for eyes with
combined traction and rhegmatogenous retinal de-
tachment are generally worse than for eyes with
purely tractional detachment. In this combined reti-
nal detachment subgroup, visual improvement is re-
ported in 32% to 53% and a final visual acuity of
20/200 or better in 25% to 36% (Table 3).124,144
TABLE 4
Visual Acuities 2 Years Postoperatively in Two Studies*
DRVS ETDRS
(Early Group) (%) (All Eyes) (%)
(N  253) (N  150)
 20/40 24.5 28.0
 20/40–20/100 17.1 20.0
 20/100–20/400 18.9 19.3
 20/400–5/200 3.6 8.0
 5/200 36.0 24.7
* DRVS  Diabetic Retinopathy Vitrectomy Study;
ETDRS  Early Treatment Diabetic Retinopathy Study.
VITRECTOMY FOR DIABETIC RETINOPATHY 503

All too often, the final visual acuity outcome is lim- operative complications, these are not unique to
ited, even though the anatomic objectives of clear- vitrectomy in diabetic patients.
ing the media and eliminating surface traction or
retinal detachment were achieved. This is usually at- Public Health Considerations
tributable to macular diseases, including cystoid mac-
As the technical upper limits in treating certain
ular edema, organized hard exudates, or capillary non-
conditions are asymptotically approached, much at-
perfusion, which may be evident as vascular sclerosis
tention has been directed toward optimal applica-
and retinal thinning (“featureless retinopathy”).
tion of preventive therapies.14,15,117 Javitt et al showed
COMPLICATIONS OF PREVIOUS VITRECTOMY the cost-effectiveness of timely and appropriate ap-
plication of PRP as recommended from collaborative
In eyes undergoing repeat vitrectomy for compli-
National Eye Institute–sponsored laser studies.79
cations after initial vitrectomy, the visual acuity out-
Medical care expenditures are being increasingly
comes are generally poor, but visual acuity may be
scrutinized. The high costs of complex surgical
maintained or improved in some patients. In a re-
cases, such as pars plana vitrectomy, have come
port of 41 eyes undergoing reoperation, the visual
under particular scrutiny and, indeed, have been a
acuity outcome varied with the specific indication
target of significant reimbursement reductions. The
for reoperation. Rhegmatogenous retinal detach-
field of outcomes research has emerged to evaluate
ment in the reoperation subset generally carried the
the effectiveness of various treatment resources.
worst prognosis, whereas recurrent vitreous hemor-
These studies have been mostly focused on the func-
rhage had a better prognosis.29 Overall, 56% had fi-
tional outcome of patients undergoing cataract sur-
nal visual acuity of light perception or no light per-
gery.140 Outcomes research relies heavily on “patient
ception, including 32% with phthisis and 94% with
satisfaction” and patients’ perceptions of their func-
rubeosis iridis. Silicone oil use is more often consid-
tional utility, which are difficult to quantitate be-
ered in this group and is associated with modest de-
cause of their subjective nature. For example, objec-
grees of success.26,28,57,69,77,97,125,155
tive measures of functional status were developed
and studied in a series of 213 diabetic patients who
Complications underwent vitrectomy for complications of prolifera-
tive diabetic retinopathy.136 In this series the oper-
The principal complications of pars plana vitrec-
ated-on eye became the better-seeing eye in 32% of
tomy in diabetic patients include recurrent vitreous
patients and equal to the fellow eye in 16%. These
hemorrhage, retinal detachment, and rubeosis iri-
patients had an average 61% preoperative visual sys-
dis.4,111,128,150 Some degree of postoperative vitreous
tem disability (as determined by American Medical
hemorrhage occurs in virtually all cases, but is con-
Association guidelines) because of the high fre-
sidered to be severe in about 30% of cases.128 The in-
quency of fellow-eye disease, but the disability was
cidence of vitreous hemorrhage is not increased in
improved postoperatively to 50%. Improvements
patients taking therapeutic doses of aspirin.38 Most
were larger in eyes without preoperative retinal de-
self-limited vitreous hemorrhages probably result
tachment. Similar outcomes were found in analyses
from clot lysis of cut ends of dissected fibrovascular
of nondiabetic vitreoretinal procedures131 and in the
tissue. Persistent or recurrent hemorrhages are
same study cohort were found to represent worth-
more commonly caused by reproliferation of retinal
while outcomes, as measured by patient satisfaction
fibrovascular tissue. Another cause of persistent post
surveys.130 Vitrectomy may increase quality of life even
operative bleeding is probably fibrovascularization
with comorbidity, such as in hemodialysis patients.109
at a sclerotomy site.128 Management options include
office-based fluid-gas exchange,95,105 vitreous lavage,
or repeat vitrectomy. Before reoperation, a waiting Conclusions
period of a few weeks is generally recommended to The indications for and timing of pars plana vit-
allow spontaneous clearing. The rates of postopera- rectomy for diabetic retinopathy continue to evolve,
tive retinal detachment and neovascular glaucoma but they have not changed conceptually. The thresh-
vary with the preoperative diagnoses, but they may olds for performing surgery in established indicated
occur in up to 20% of cases. In cases with poorly situations have generally been lowered, but only a
controlled neovascular glaucoma, procedures such few additional indications have been established.
as Molteno or Baerveldt tube placements may be The lowered threshold is attributable to improve-
considered, as standard glaucoma filtering surgery is ments in both instrumentation and surgical tech-
usually unsuccessful.91,148 Also, the risk of endoph- niques. Accordingly, more difficult cases are now be-
thalmitis after vitrectomy is higher in diabetic pa- ing considered for vitrectomy, and postoperative
tients.39 Although there may be other potential post- recovery of vision is more consistent.
504 Surv Ophthalmol 43 (6) May–June 1999
Although visual acuity outcomes after vitrectomy
are favorable compared to the natural course, they
are still poor compared to the potential efficacy of
preventive measures, such as improved control of
glucose levels and timely application of laser treat-
ment. The objective of the Diabetes 2000 Project is
education of ophthalmologists, primary care physi-
cians, and ancillary medical providers in order to re-
duce preventable visual loss from diabetic retinopa-
thy.117 A new potential treatment may follow from
the exciting discovery and work with vascular endot-
helial growth factor, levels of which are elevated in
eyes with proliferative diabetic retinopathy.7,9,10,13 De-
spite optimal medical and ophthalmologic manage-
ment, at least 5% of eyes will have progressive retin-
opathy leading to the need for laser treatment and
pars plana vitrectomy.61 Furthermore, about 20% of
patients undergong vitrectomy for complications of
diabetic retinopathy ultimately require bilateral vit-
rectomy.136 Because the long-term stability of initially
successful treatment is good,63 and the life expec-
tancy after diabetic vitrectomy is relatively favorable,71
pars plana vitrectomy remains an essential tool in
the management of severe complications from dia-
betic retinopathy.
Methods of Literature Search
The MEDLINE database was searched from 1995
whereas through 1997, in all languages, with the use
of the terms diabetic retinopathy and vitrectomy. Articles
in German, Spanish, and French could be under-
stood by the authors, whereas articles from other
languages were excluded.
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