From the Guidelines
Macular puckering in diabetic patients is a serious condition that requires prompt referral to an ophthalmologist and may be treated with vitrectomy surgery, intravitreous injections of anti-vascular endothelial growth factor, or panretinal laser photocoagulation therapy, depending on the severity of symptoms and impact on vision. The condition, also called epiretinal membrane, occurs when scar tissue forms on the macula, causing visual distortion and decreased acuity. In diabetic patients, macular puckering is often more severe due to underlying diabetic retinopathy, with complications including accelerated vision loss, increased risk of macular edema, and potential for tractional retinal detachment.
Some key points to consider in the management of macular puckering in diabetic patients include:
- The importance of prompt referral to an ophthalmologist for patients with any level of diabetic macular edema, moderate or worse nonproliferative diabetic retinopathy, or any proliferative diabetic retinopathy, as recommended by the standards of care in diabetes-2024 1.
- The use of intravitreous injections of anti-vascular endothelial growth factor as a first-line treatment for most eyes with diabetic macular edema that involves the foveal center and impairs vision acuity, as indicated by the standards of medical care in diabetes-2022 1.
- The role of panretinal laser photocoagulation therapy in reducing the risk of vision loss in individuals with high-risk proliferative diabetic retinopathy and, in some cases, severe nonproliferative diabetic retinopathy, as stated in the standards of care in diabetes-2023 1.
- The need for strict blood glucose control before and after surgery, with a target HbA1c below 7%, to optimize surgical outcomes and reduce complications, as emphasized in the standards of medical care in diabetes-2021 1.
Treatment options depend on symptom severity and impact on vision. For mild cases with minimal symptoms, observation with regular monitoring every 3-6 months is appropriate. When vision is significantly affected, the primary treatment is vitrectomy surgery with membrane peeling, which involves removing the vitreous gel and carefully peeling away the epiretinal membrane. Post-operative care includes antibiotic eye drops, anti-inflammatory drops, and regular follow-up visits. Visual recovery is typically gradual, with improvement continuing for 3-6 months after surgery, though complete restoration to normal vision may not occur in all cases due to long-standing retinal changes.
From the FDA Drug Label
1.3 Diabetic Macular Edema (DME) 1.4 Diabetic Retinopathy (DR) 2.4 Diabetic Macular Edema (DME) and Diabetic Retinopathy (DR) 5.4 Fatal Events in Patients with Diabetic Macular Edema and Diabetic Retinopathy at Baseline
The FDA drug label does not answer the question about puckering of macula due to diabetes, but it does mention Diabetic Macular Edema (DME) and Diabetic Retinopathy (DR) as indications for the drug ranibizumab 2.
- Diabetic Macular Edema (DME) is a complication of diabetes that causes fluid to build up in the macula, leading to swelling and vision problems.
- Diabetic Retinopathy (DR) is a complication of diabetes that causes damage to the blood vessels in the retina, leading to vision problems. However, macular puckering is not directly mentioned in the label. Treatment options for DME and DR include ranibizumab, but the label does not provide information on the specific treatment of macular puckering.
From the Research
Complications of Macular Puckering in Diabetic Patients
- Macular puckering, also known as epiretinal membrane (ERM), is a complication that can occur in diabetic patients, leading to vision loss and distortion 3
- Diabetic macular edema (DME) is a major cause of vision impairment in diabetic individuals, characterized by fluid accumulation in the macula due to a breakdown of the blood-retinal barrier (BRB) 4
- The presence of ERM in patients with DME can lead to significant improvement in visual acuity, macular thickness, and reduction in intravitreal injections after pars plana vitrectomy (PPV) with ERM peeling 3
Treatment Options for Macular Puckering in Diabetic Patients
- Anti-vascular endothelial growth factor (anti-VEGF) therapies, including ranibizumab, bevacizumab, and aflibercept, have revolutionized the management of DME by targeting VEGF, a key mediator in DME pathogenesis 4, 5
- Panretinal photocoagulation (PRP) can prevent progression of proliferative diabetic retinopathy with minimal risk of damaging the macula 6
- Vitrectomy, scleral buckling, epiretinal membrane peeling, and retinal detachment repair are surgical treatment options for diabetic retinopathy, including macular puckering 7
- Early detection and treatment of diabetic retinopathy are crucial to avoid complications and maintain vision 7
Risk Factors and Management
- Chronic hyperglycemia, hypertension, and hyperlipidemia are risk factors for diabetic retinopathy and macular puckering 6, 7
- Optimization of glycemic control, blood pressure management, control of diet and lipid levels, and lifestyle modification can help slow the progression of diabetic retinopathy 6
- Smoking cessation is recommended for patients with age-related macular degeneration, which can also be a risk factor for macular puckering 6