Surgeon: Vitrectomy with triamcinolone and ILM peeling best treatment for CME

VIENNA, Austria — Despite many studies, cystoid macular edema remains an unsolved problem after 40 years of evidence-based treatment.

According to Peter Wiedemann, MD, the most effective approach is vitrectomy with internal limiting membrane (ILM) peeling. Triamcinolone is an essential tool to the success of the procedure.

"The rationale for vitrectomy is that it conveys oxygen from the ciliary body to the retina. In diabetes, the vitreous is very adherent to the retina, and a spontaneous reabsorption of the edema occurs in more than 25% of the cases where vitreous detaches," Dr. Wiedemann said at the Euretina Congress here.

Laser photocoagulation also brings oxygen to the retina, but of all the treatments it is the most destructive, with negative effects on retinal thickness and vision.

Dr. Wiedemann emphasized that in performing vitrectomy for CME, triamcinolone is useful. Macular edema may be caused by cytotoxic changes or, for vasogenic cases, by high blood pressure.

"Triamcinolone inhibits the inflammatory mediators and the production of VEGF and opens the channels specifically to remove calcium and water from the cells. So, it works against cytotoxic edema. Studies have shown that it is also more effective than anti-VEGF," he said.

The anti-edematous effect is prolonged with repeated treatments.

As a surgical tool during vitrectomy, triamcinolone is useful in providing better visualization of the transparent vitreous and therefore allows easier, better and more complete removal of the posterior hyaloid from the ILM, he said.

"Residual collagen fibers and cellular components tend to remain on the ILM if you don't use it," Dr. Wiedemann noted.

As far as ILM peeling is concerned, there is no uniform consent on its benefits and its impact on foveal thickness and visual acuity.

"I believe that this is due to the method of ILM removal. There are different techniques, and different results are correlated to them," he noted.

In his opinion, ILM peeling is indeed useful in diabetic CME.

Dr. Wiedemann said that his personal approach is basic treatment with glycemia and blood pressure control, no laser, vitrectomy with triamcinolone and ILM peeling with a short exposure time, and no yellow light.

"The benefits of additional anti-VEGF and additional triamcinolone should be assessed in the future, and randomized trials should be performed to find the best treatment solution and provide surgeons with uniform, validated guidelines," he noted.