الفهرس 
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Abstract
Macular edema is the most common cause of visual impairment in people all over the world. The increasing number of individuals with diabetes worldwide suggests that diabetic macular edema (DME) is a common complication of diabetes mellitus & continue to be a major contributor to vision loss and associated functional impairment for years to come. The treatment of DME has evolved significantly over the past decade. Inhibitors of vascular endothelial growth factor (VEGF) have demonstrated remarkable efficacy in clinical trials and have become the gold standard for DME treatment, replacing macular laser photocoagulation. Many previous studies have demonstrated that anti-VEGFS have significant effects on the treatment of DME with reductions in macular edema and gains in visual acuity. In some patients, optimal DME control was not achieved using anti-VEGFS; this group of patients is defined as persistent or refractory DME. The prevalence of refractory DME is estimated to be around 50%. In our study we propose that macular edema becomes persistent if central foveal thickness remains above 275um despite at least three intravitreal injections of anti VEGF agents. Refractory persistent DMO can cause irreversible loss of vision due to chronic tissue stress and permanent disruption of retinal architecture from the edema, ultimately causing photoreceptor loss. Although delayed treatment may lessen the edema on OCT, the visual acuity gain may be suboptimal in such eyes with chronic DMO due to irreversible retinal damage. There is many therapeutic options for management of refractory macular edema either switching anti VEGF agents, corticosteroids, focal laser and lastly surgical interference. The aim of the study is to evaluate the effectiveness and safety of planned foveal detachment technique for the resolution of diabetic macular edema resistant to Anti Vascular Endothelial Growth Factor (Anti VEGF) therapy as regard anatomy and function of the macula. Optical coherence tomography (OCT) permits detailed assessment and quantification of the degree and type of edema and, as such, is considered essential for determining whether visual impairment is due to diabetic macular edema or not. This study included 18 eyes of 18 patients. With diabetic macular edema resistant to anti VEGF therapy after they had met the inclusion / exclusion criteria. This is a prospective interventional noncomparative case series study to evaluate the efficacy and safety of planned foveal detachment technique for the rapid resolution of diabetic macular edema resistant to Anti Vascular Endothelial Growth Factor (Anti VEGF) therapy and follow up for 6 months by OCT analysis to evaluate the effects of this surgical technique on the morphologic characteristics of the retina and best corrected visual acuity to assess functional improvement. OCT used to assess central foveal thickness to evaluate anatomical improvement in response to planned foveal detachment and best corrected visual acuity to assess functional improvement in response to rapid edema resolution. Treatment outcomes were changes in BCVA and OCT parameters after surgery compared to baseline examination. The present study showed that there was post operative significant improvement of BCVA in 6 patients (33.3%) from 0.063±0.04 to 0.22±0.11 six months post operative (group B).No change of BCVA was observed during follow up of 6 cases(33.3%)(group A).this was explained by preoperative poor BCVA and interruption of external limiting membrane (ELM) and inner segment /outer segment of photo receptors. However, group C that included another 6 patients (33.3%) showed post-operative significant reduction of BCVA from 0.20±0.07 to 0.10±0.05 six months post-operative due to significant cataract development in 2 cases and recurrence of macular edema in 4 cases. These changes in BCVA after the operation not significantly correlated with demographic data of the involved cases ,but there was a negative correlation between post operative changes in BCVA and HbA1C values. Cases that showed postoperative improvement of BCVA had good glycemic control with HbA1C <7.also, there was a negative correlation between post operative changes in BCVA and control of systemic blood pressure with post operative improvement of BCVA in patients with controlled systemic blood pressure <140/90.As regard type of diabetes,IDDM has a negative impact on the condition with percentage of patients showing post operative improvement of BCVA 66.6 % in NIDDM group and 33.3% in IDDM group. The present study showed that the preoperative mean CFT was 585.78±112.59 with significant post operative reduction to 483.67±208.73 one week after surgery ,also significant reduction of central foveal thickness was noticed 1 month,3 months and 6 months post operative compared with preoperative values. But there is no cases with reduction in CFT ≥50 % of preoperative values at 1 week follow up and only 4 cases(22.2%) with reduction in CFT ≥50 % of preoperative values at 6 months follow up. There is negative correlation between changes in CFT at 6 month follow up and HbA1C values with post-operative reduction of CFT by more than 50% in cases with mean preoperative HBA1C5.75±0.288 (P=0.09 ), mean systolic and diastolic blood pressure 135.0±5.77 (P=0.675), 85.0±5.77 (P=0.597) respectively. Poor baseline BCVA, older age, long duration of the disease, poor control of systemic condition as regard HbA1C, blood pressure and lipid profile predict poorer visual outcomes in patients with refractory diabetic macular edema.