A New Option in Retinal Edema Surgery: Cystotomy as a Treatment for Refractory Macular Edema

A New Option in Retinal Edema Surgery: Cystotomy as a Treatment for Refractory Macular Edema

Retinal edema, perticularly macular edema, is a condition that can significantly impact central vision, making everyday activities such as reading or recognizing faces difficult. This swelling in the central retina, or macula, often results from underlying retinal vascular diseases such as diabetic retinopathy (DR) and branch retinal vein occlusion (BRVO). Despite advancements in treatment, some cases of macular edema do not respond to standard therapies. For these patients, a new surgical approach known as cystotomy could be a potential option in retinal edema surgery among other available treatments.

Understanding Refractory Macular Edema

Macular edema occurs when fluid leaks from damaged blood vessels into the retinal tissue. Treatments such as anti-VEGF injections, corticosteroids, laser photocoagulation, and even vitrectomy have shown success in many cases. However, a subset of patients experiences persistent swelling that does not resolve—this is known as refractory cystoid macular edema (CME).

Current Therapeutic Options for Retinal Edema

1. Anti-VEGF Therapy: The most commonly used first-line treatment involves medications like ranibizumab or aflibercept. These injections target vascular endothelial growth factor (VEGF), which promotes fluid leakage. Many patients benefit, but others require frequent injections and still have persistent edema.

2. Corticosteroid Injections: Steroids such as triamcinolone acetonide or dexamethasone implants reduce inflammation and fluid leakage. While effective for some, they can increase the risk of intraocular pressure and cataract formation.

3. Laser Photocoagulation: This technique seals leaking blood vessels and can be effective in localized edema. However, it is less helpful in diffuse or central macular swelling and may cause permanent retinal scarring.

4. Pars Plana Vitrectomy (PPV): Often used when traction or epiretinal membranes contribute to edema. It involves removing the vitreous gel, but edema may persist even after surgery.

Despite these options, a percentage of patients still suffer from refractory CME. In these cases, an alternative surgical strategy may be needed.

Introducing Cystotomy

Cystotomy is a microsurgical technique that have developed to address cases of macular edema that do not respond to other treatments. It involves making a very small incision in the wall of the cystoid cavity within the macula to release fluid. In some cases, a fibrinogen clot—a dense accumulation of protein—can be found and removed during the procedure.

This method is typically performed alongside pars plana vitrectomy using delicate 27-gauge instruments. While it may seem minor, this incision allows accumulated fluid and, when present, fibrinogen debris to be cleared from the macula.

The Surgical Process in Brief

The procedure is performed under local or general anesthesia and includes:

1.     Pars plana vitrectomy to access the macula

2.     A precise incision into the cyst wall

3.     Gentle removal of any fibrinogen clots if visible

4.     Closure and postoperative observation

Conclusion

Cystotomy represents a contribution to the ongoing challenge of treating stubborn macular edema. While it may not replace first-line treatments, it offers a new path forward for patients who have not responded to standard therapies. Through careful patient selection and precise surgical technique, cystotomy may help restore vision and quality of life in difficult cases. If you or someone you know is living with persistent retinal edema, we encourage you to explore all options—and consider whether cystotomy might be one of them.