Title : A comprehensive approach to the treatment of proliferative diabetic retinopathy complicated by tractional retinal detachment: experience with perioperative thromboelastography
Abstract:
Objectives: The primary goals of vitreoretinal surgery for tractional retinal detachment in diabetic retinopathy include:
- Minimizing intra? and postoperative hemorrhages.
- Ensuring optical media transparency.
- Releasing traction from fibrovascular membranes on the retina.
- Preventing retinal damage.
- Reducing reliance on silicone tamponade.
- Hemostasis Assessment Rationale
During fibrovascular membrane dissection, there is a risk of injuring vessels traversing the membrane, making proper fibrin clot formation critical. Since the hemostasis system in diabetes is labile—capable of changing within a single day—it is essential to assess hemostasis on the day of surgery, rather than two weeks in advance, as is typical in elective procedures.
Thromboelastography (TEG): TEG is the most comprehensive method for evaluating hemostasis in surgical planning. It provides graphical recording of coagulation and fibrinolysis processes in blood, tracking changes in viscosity and elasticity of the developing clot. The resulting curve illustrates clot formation dynamics.
Objective: To assess the efficacy of a multidisciplinary approach in treating proliferative diabetic retinopathy complicated by tractional retinal detachment, using perioperative TEG for hemostasis assessment and correction.
Materials and Methods: The study included 29 patients with tractional diabetic retinal detachment. On the morning of surgery (7:00?AM), venous blood was collected from each patient and sent to the hemostasiology department. Blood coagulation was recorded in a specialized cuvette, and by 9:00?AM, thromboelastogram data and recommendations for surgery and potential correction were available.
Results: 25 patients: thromboelastogram parameters were normal, 4 patients: coagulation abnormalities of varying severity were detected, with recommendations for correction provided.
Illustrative Clinical Case: Patient?M., 31 years old, monocular (only one functional eye), diagnosed with proliferative diabetic retinopathy and tractional retinal detachment; HIV?positive status:Preoperative visual acuity (Visus): hand motion eccentric. Preoperative assessment: normal hemostasis; preserved immune status.
On surgery day, TEG revealed fibrinolysis, necessitating antifibrinolytic therapy. Following hemostasis correction, intraoperative bleeding remained minimal and controllable despite dense fibrovascular membranes adhering to the retina (including macular area), without impairing visualization.
Postoperative visual acuity:
- 1?week: 0.05 (uncorrected).
- 1?month: 0.1 (uncorrected), stable.
- Intraocular Hemorrhage Control Measures
Key strategies for managing intraocular bleeding include: Maintaining low glycemic variability; stabilizing glucose levels; targeting HbA1c?<?7% (if possible) on surgery day and during the first postoperative week. Administering an anti?angiogenic agent intravitreally 3–5?days before surgery. Using intravenous tranexamic acid (10?mg/kg bolus) during membrane dissection, repeated at 8?h and 12?h postoperatively. Controlling intraoperative blood pressure via nitrate infusion. Avoiding vascular loop resection; limiting transient intraocular pressure (IOP) elevation (≤?3?min); performing endocoagulation for hemorrhage. Implementing stepwise intra? and postoperative panretinal laser photocoagulation.
Conclusions: A comprehensive approach to managing diabetic retinopathy complications stabilizes the proliferative process, improves visual function, and supports patient rehabilitation. This enhances adherence to glucose?lowering therapy and improves long?term survival prospects. A multidisciplinary approach and collaboration with colleagues from related specialties are crucial for optimal patient care.
