Surgical Management of Thick Taut Posterior Hyaloid in Diabetic Retinopathy
Diagnosis
- The American Academy of Ophthalmology recommends stereoscopic slit-lamp biomicroscopy with fundus contact lens after pupillary dilation to identify the taut posterior hyaloid, creating tangential traction at the macula 1, 2
- Optical Coherence Tomography (OCT) provides high-resolution imaging of the vitreoretinal interface and can demonstrate the attached posterior hyaloid and associated macular thickening, with a strength of evidence level I 2
- Fluorescein angiography shows deep and diffuse pattern of leakage in the macula and helps identify macular capillary nonperfusion, which is a negative prognostic factor for surgical outcomes 2, 3
- B-scan ultrasonography is essential when media opacity prevents adequate visualization of the posterior hyaloid and retina, and can assess vitreoretinal traction and rule out retinal detachment 3
Management
- The American Academy of Ophthalmology recommends vitrectomy with posterior hyaloid removal for persistent diffuse diabetic macular edema unresponsive to laser therapy when a taut posterior hyaloid is identified, with a favorable prognostic factor being preoperative visual acuity better than 20/200 1, 4
- Vitrectomy with posterior hyaloid removal is performed using a 23-, 25-, or 27-gauge vitrectomy system with local monitored anesthesia, and the attached, thickened posterior hyaloid is lifted and separated from the retina using aspiration, an illuminated pick, or forceps 4
- Pre-operative anti-VEGF treatment may be beneficial, reducing duration of surgery, decreasing number of intraoperative retinal breaks, and reducing intraoperative bleeding, with a strength of evidence level II 1
- Cataract management is crucial, as the risk of cataract progression following vitrectomy in phakic eyes is high, and cataract surgery may be performed before, during, or after vitrectomy depending on clinical circumstances 4