Impact of epiretinal membrane surgery on glaucoma progression: influence of glaucoma severity and internal limiting membrane peeling.

To report the surgical outcome of pars plana vitrectomy (PPV) without internal limiting membrane (ILM) peeling in three highly myopic patients with macular retinoschisis and associated posterior staphyloma. We report three highly myopic patients with macular retinoschisis and foveal detachment who underwent simple PPV without ILM peeling, with long-acting gas tamponade. Main outcome evaluations included best corrected visual acuity, biomicroscopic appearance and optical coherence tomography findings. Pars plana vitrectomy without ILM peeling resulted in anatomic and functional improvement in all three operated eyes for follow-up periods of > or = 12 months. Pars plana vitrectomy without ILM peeling is effective for treating macular retinoschisis and foveal detachment in highly myopic eyes with posterior staphyloma. Visual and anatomic outcomes are comparable with those in previous studies in which ILM removal was performed.

We describe a useful surgical technique for the treatment of idiopathic epiretinal membrane with concurrent internal limiting membrane (ILM) defect, in which ILM peeling was started from the ILM defect margin. A dissociated optic nerve fiber layer-like appearance on fundus examination and optical coherence tomography may suggest an ILM defect.

Purpose: Evaluation of the visual and anatomical outcomes following idiopathic macular epiretinal membrane (ERM) removal, with or without internal limiting membrane (ILM) peeling, and review of the literature.Methods: A retrospective study of 39 eyes operated for idiopathic ERM was conducted. Pars plana vitrectomy was combined with ERM removal and Indocyanine green (ICG) assisted ILM peeling in 24 eyes.Results: In Group A (without ILM peeling), mean preoperative BCVA was 0.48 logMAR (0.3 in decimal units), whereas mean postoperative BCVA was 0.37 logMAR (0.4 in decimal units). In Group B (with ILM peeling), mean preoperative BCVA was 0.58 logMAR (0.25 in decimal units), whereas mean postoperative BCVA was 0.31 logMAR (0.5 in decimal units). No statistically significant difference was observed between Groups A and B regarding preoperative or postoperative BCVA (p>0.1, Student’s t-test).OCT measurement of postoperative foveal thickness reveled a significant decrease in thickness in both groups; however, no correlation was observed between postoperative BCVA and postoperative foveal thickness (Pearson’s correlation coefficient = 0.139; p>0.1).Conclusions: In spite of final visual acuity improvement following idiopathic ERM removal, recovery of a normal foveal thickness is not achieved in the majority of the cases. ICG assisted ILM peeling does not affect the functional outcome of idiopathic ERM removal.

BackgroundThe epiretinal membrane (ERM) is a nonvascular fibrocellular tissue formed by cellular metaplasia and proliferation at the vitreoretinal surface and is generally treated by pars plana vitrectomy (PPV) with or without internal limiting membrane (ILM) peeling. This network meta-analysis aimed to compare the efficacy of all available ERM removal interventions and assessed the use and efficacy of surgical dyes in managing idiopathic ERMs.MethodsMEDLINE, EMBASE, Cochrane CENTRAL, and the US National Library of Medicine were searched (June 28, 2023). Clinical studies that included patients with ERMs were included. Randomized controlled trials (RCTs) were also appraised using Cochrane risk of bias (ROB).ResultsTen RCTs and ten non-RCTs were included in this study. A pairwise meta-analysis between ERM removal and combined ERM and ILM removal showed no significant difference in visual outcome (change in BCVA) 1 year postintervention (MD = − 0.0034, SE = 0.16, p = 0.832). Similarly, there was no significant difference in the central macular thickness postoperatively between the two groups (MD = − 4.95, SE = 11.11, p = 0.656) (Q = 4.85, df = 3, p = 0.182, I2 = 41.21%). The difference in ERM recurrence between the groups was also not statistically significant (OR = 4.64, p = 0.062, I2 = 0). In a network meta-analysis, there was no significant difference in visual outcomes between ERM removal only and other treatment modalities: combined ILM and ERM removal (MD = 0.039, p = 0.837) or watchful waiting (MD = 0.020, p = 0.550). In a network meta-analysis, there was no significant difference in the visual outcomes between ERM removal alone and dye-stained combined ERM and ILM peeling (MD = 0.122, p = 0.742 for brilliant blue G; BBG and MD = 0.00, p = 1.00 for membrane blue-dual; MBD). The probability of being a better surgical dye for better visual outcomes was 0.539 for the MBD group and 0.396 for the BBG group. The recurrence of ERM was not significantly different when the ILM was stained with any of the dyes. No study was judged on ROB assessment as having low ROB in all seven domains.ConclusionThe two types of surgical modalities provided comparable efficacy, with no significant differences between the outcomes. Among the dye-assisted ILM peeling methods, the membrane blue-dual dye was the most effective in providing better structural and functional outcomes.

The purpose of the present paper was to evaluate the visual outcome and recurrence rate of epiretinal membrane (ERM) formation following vitreoretinal surgery with and without internal limiting membrane (ILM) peel. The medical records of 42 consecutive patients who underwent surgery for macular ERM by a single surgeon were reviewed. All patients underwent pars plana vitrectomy and ERM removal with a subset undergoing ILM peel. Recurrence of macular ERM within 18 months and the final visual outcome after surgery were compared between patients with and without ILM removal. Twenty-five patients (59.5%) underwent ERM surgery with ILM peeling and 17 patients (40.5%) underwent ERM surgery without ILM peeling. The mean preoperative logMAR visual acuity was 0.77 and 0.96 for the ILM peeling and non-ILM peeling groups, respectively. Visual acuity improved significantly in both the ILM and non-ILM peeling groups after ERM surgery (P < 0.001 and P = 0.003, respectively). Eighteen months after surgery, 3/17 eyes without ILM peeling (17.6%) developed recurrent macular ERM, compared with none of the 25 eyes with ILM peeling (log-rank test, P = 0.030). Internal limiting membrane removal during macular ERM surgery may minimize the recurrence of ERM, without adverse visual outcome. Further controlled prospective studies are needed to determine the role of ILM peeling in ERM surgery.

Internal Limiting Membrane Peeling For Primary Rhegmatogenous Retinal Detachment Repair

Indocyanine green-assisted internal limiting membrane removal in epiretinal membrane surgery: A clinical and histologic study

To assess the outcome of simultaneous phacoemulsification, pars plana vitrectomy and intraocular lens (IOL) implantation in eyes with macular hole. A retrospective study was conducted in 38 eyes (36 patients) after combined phacoemulsification, insertion of a posterior capsule IOL and pars plana vitrectomy. The macular hole was successfully closed in 32 of the 38 eyes (84%). In six eyes (16%) the hole failed to close and one eye underwent a second operation. Vision improved by two or more Snellen lines in 29 eyes (73%), there was no change in seven eyes (18%), and visual acuity decreased in two eyes (5%). Intraoperative and postoperative complications included retinal tears in nine eyes (24%), posterior capsule rupture in two eyes (5%), transient postoperative increase of intraocular pressure in eight eyes (21%), and posterior capsule opacification in five eyes (13%). Combining phacoemulsification, IOL insertion and pars plana vitrectomy for macular hole repair can reduce the need for cataract surgery in the future, decrease costs, shorten postoperative recovery time and allow for clearer intraoperative visualization, making the procedure safer and more effective.

Aim This is a prospective comparative study of the macular morphology and visual outcome after epiretinal membrane (ERM) removal with and without internal limiting membrane (ILM) peeling in cases of idiopathic ERM. The study was carried out in the Research Institute of Ophthalmology, Giza, Egypt from February 2015 to February 2017. Patients and methods A total of 40 eyes of 40 patients with visually significant idiopathic ERM were included in the study. A standard three-port 23-gauge pars plana vitrectomy (PPV) was conducted in all patients. Twenty eyes (Group A) were subjected to ERM removal only, while ILM peeling with ERM removal was performed in the other 20 eyes (Group B). Central macular thickness (CMT) and foveal contour on optical coherence tomography (OCT) in addition to best-corrected visual acuity (BCVA) were obtained at baseline and at 1, 3, 6 and 12months postoperatively. Results The mean BCVA significantly improved in both groups, with no statistically significant difference between the two groups at 12 months postoperatively (P=0.053). The mean preoperative and postoperative BCVA were 0.19 and 0.50 decimal units, respectively, in group A, while in group B, the mean preoperative and postoperative BCVA were 0.13 and 0.44 decimal units, respectively. Despite a statistically significant more reduction of CMT in group A compared with group B at 1 month postoperatively (324.80 and 403.95 µm, respectively, P=0.01), no statistically significant difference was found between the two groups at 12 months postoperatively (277.40 and 306.20 µm, respectively). Normal foveal contour was achieved in 13 (65%) and 6 (30%) eyes in groups A and B, respectively. Conclusion Anatomical and functional improvements could be achieved in both groups, with no statistically significant difference at 12 months postoperatively. Adding ILM peeling to idiopathic ERM removal did not appear to improve the outcome in this cohort. Therefore, ILM should not be routinely peeled as safety remains controversial.

Dear Editor In the setting of a rhegmatogenous retinal detachment (RRD), retinal pigment epithelial (RPE) cells are released into the vitreous cavity and thought to provoke formation of proliferative vitreoretinopathy (PVR) membranes and PVR-related epiretinal membranes (ERM) following RRD surgery using the internal limiting membrane (ILM) as a scaffold (Fallico et al., 2018). Previous studies have suggested that there may be a reduction in ERM formation following repair of RRDs with prophylactic intra-operative ILM peeling (Yannuzzi et al., 2018) and potential better single surgery success. However, a clear benefit in final visual acuity or surgical success has not been established (Bawankule et al., 2019). The purpose of this paper was to examine the postoperative outcomes of eyes without preoperative macular pathology undergoing primary RRD surgery with and without the use of prophylactic ILM peeling during pars plana vitrectomy (PPV), in a large multicenter study. We report a subgroup analysis from the Primary Retinal Detachment Outcomes (PRO) study, which has been previously described in detail (Ryan, in Press). For the current study, consecutive patients with primary RRD who underwent repair with either primary PPV or a combination of PPV and scleral buckling from 1 January 2015, through 31 December 2015, from 6 centres across the country were included in the analysis. Eyes that had preoperative ERM, PVR or macular hole were excluded, meaning that this study only examined patients who had prophylactic ILM peeling in primary RRD without any macular pathology that would bias towards ILM peeling for other reasons. The primary outcome was single surgery anatomic success with secondary outcomes of final postoperative visual acuity and the development of postoperative ERM formation. There were 1442 eyes that met the inclusion criteria, with 41 eyes (2.8%) undergoing concomitant ILM peeling at the time of RRD surgery. Comparing eyes that underwent ILM peeling during RRD surgery versus those that did not revealed no significant differences in concomitant SB surgery, number of retinal breaks, pre- and postoperative visual acuity, macular detachment status, number of secondary retinal surgeries, or in the development of postoperative ERM (Table 1). Eyes that underwent ILM peeling had a significantly higher single surgery success rate following primary RRD repair (95% vs 85%, p = 0.03). This was maintained on multivariate analysis controlling for preoperative macular status, surgeon identification and type of retinal detachment surgery (p = 0.02). One eye (2.4%) developed an ERM post-ILM peeling while 21 (1.5%) developed an ERM in the non-ILM peeling cohort (p = 0.47). We report that eyes without preoperative macular pathology undergoing ILM peeling at the time of RRD repair had higher single surgery success rates. There were no differences in postoperative ERM formation or final visual acuity. There is thought that by peeling the ILM prophylactically during RRD repair, the residual posterior cortical gel is completely removed as well as the scaffold on which cellular proliferation may develop, which may limit posterior PVR formation and perhaps prevent recurrent detachments (Hisatomi et al., 2018). It is plausible that by removing the ILM only within the arcades may be sufficient to remove more of the posterior cortical gel in enough high-risk eyes, or those with vitreoschisis, and prevent posterior PVR from applying traction on the peripheral retina. As with any surgical study with numerous different surgeons, a number of intra-operative factors cannot be accounted for that certainly could bias the results, such as the area of the ILM peel, dyes used to stain the ILM and different techniques for ILM peeling. Still, we report a significantly higher single surgery success rate in eyes that underwent peeling of the ILM during RRD surgery. Despite this anatomic success, there were no differences in final visual acuity or postoperative ERM formation between eyes with and without concomitant ILM peeling during RRD repair.

Macular hole (MH) is a full-thickness defect in the central portion of the retina that causes loss of central vision. According to the usual definition, a large MH has a diameter greater than 400 µm at the narrowest point. For closure of MH, there is evidence that pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling achieves better anatomical outcomes than standard PPV. PPV with ILM peeling is currently the standard of care for MH management; however, the failure rate of this technique is higher for large MHs than for smaller MHs. Some studies have shown that the inverted ILM flap technique is superior to conventional ILM peeling for the management of large MHs. To evaluate the clinical effectiveness and safety of pars plana vitrectomy with the inverted internal limiting membrane flap technique versus pars plana vitrectomy with conventional internal limiting membrane peeling for treating large macular holes, including idiopathic, traumatic, and myopic macular holes. The Cochrane Eyes and Vision Information Specialist searched CENTRAL, MEDLINE, Embase, two other databases, and two trials registries on 12 December 2022. We included randomized controlled trials (RCTs) that evaluated PPV with ILM peeling versus PPV with inverted ILM flap for treatment of large MHs (with a basal diameter greater than 400 µm at the narrowest point measured by optical coherence tomography) of any type (idiopathic, traumatic, or myopic). We used standard methodological procedures expected by Cochrane and assessed the certainty of the body of evidence using GRADE. We included four RCTs (285 eyes of 275 participants; range per study 24 to 91 eyes). Most participants were women (63%), and of older age (range of means 59.4 to 66 years). Three RCTs were single-center trials, and the same surgeon performed all surgeries in two RCTs (the third single-center RCT did not report the number of surgeons). One RCT was a multicenter trial (three sites), and four surgeons performed all surgeries. Two RCTs took place in India, one in Poland, and one in Mexico. Maximum follow-up ranged from three months (2 RCTs) to 12 months (1 RCT). No RCTs reported conflicts of interest or disclosed financial support. All four RCTs enrolled people with large idiopathic MHs and compared conventional PPV with ILM peeling versus PPV with inverted ILM flap techniques. Variations in technique across the four RCTs were minimal. There was some heterogeneity in interventions: in two RCTs, all participants underwent combined cataract-PPV surgery, whereas in one RCT, some participants underwent cataract surgery after PPV (the fourth RCT did not mention cataract surgery). The critical outcomes for this review were mean best-corrected visual acuity (BCVA) and MH closure rates. All four RCTs provided data for meta-analyses of both critical outcomes. We assessed the risk of bias for both outcomes using the Cochrane risk of bias tool (RoB 2); there were some concerns for risk of bias associated with lack of masking of outcome assessors and selective reporting of outcomes in all RCTs. All RCTs reported postoperative BCVA values; only one RCT reported the change in BCVA from baseline. Based on evidence from the four RCTs, it is unclear if the inverted ILM flap technique compared with ILM peeling reduces (improves) postoperative BCVA measured on a logarithm of the minimum angle of resolution (logMAR) chart at one month (mean difference [MD] -0.08 logMAR, 95% confidence interval [CI] -0.20 to 0.05; P = 0.23, I2 = 65%; 4 studies, 254 eyes; very low-certainty evidence), but it may improve BCVA at three months or more (MD -0.17 logMAR, 95% CI -0.23 to -0.10; P < 0.001, I2 = 0%; 4 studies, 276 eyes; low-certainty evidence). PPV with an inverted ILM flap compared to PPV with ILM peeling probably increases the proportion of eyes achieving MH closure (risk ratio [RR] 1.10, 95% CI 1.02 to 1.18; P = 0.01, I2 = 0%; 4 studies, 276 eyes; moderate-certainty evidence) and type 1 MH closure (RR 1.31, 95% CI 1.03 to 1.66; P = 0.03, I² = 69%; 4 studies, 276 eyes; moderate-certainty evidence). One study reported that none of the 38 participants experienced postoperative retinal detachment. We found low-certainty evidence from four small RCTs that PPV with the inverted ILM flap technique is superior to PPV with ILM peeling with respect to BCVA gains at three or more months after surgery. We also found moderate-certainty evidence that the inverted ILM flap technique achieves more overall and type 1 MH closures. There is a need for high-quality multicenter RCTs to ascertain whether the inverted ILM flap technique is superior to ILM peeling with regard to anatomical and functional outcomes. Investigators should use the standard logMAR charts when measuring BCVA to facilitate comparison across trials.

BackgroundWe report for the first time a way to predict the 2-dimensional extension of an internal limiting membrane (ILM) defect by detecting the area with dissociated optic nerve fiber layer (DONFL)-like spots in the preoperative optical coherence tomography (OCT) en-face images.Case presentationsCase 1 was a 67-year-old man with metamorphopsia and decreased vision in his right eye. His best-corrected visual acuity (BCVA) was 20/100, with a pterygium, a moderate nuclear cataract, and an epiretinal membrane (ERM). Case 2 was a 73-year-old man with metamorphopsia and decreased vision in his left eye. His BCVA was 20/25, with a moderate nuclear cataract and an ERM. Both patients underwent simultaneous cataract surgery and pars plana vitrectomy with ERM and ILM peeling. Brilliant Blue G staining, performed before ERM and ILM peeling, revealed an unstained area. A careful evaluation of the area showed that it was not covered by either the ERM or ILM. A postoperative evaluation of the preoperative OCT images obtained from these cases showed DONFL-like low-brightness spots in the ILM defect area on the OCT en-face images.ConclusionsOCT en-face images may indicate the area of the ILM defect. To avoid iatrogenic damage to the retinal nerve fiber layer by touching/pinching it with forceps, detecting areas with DONFL-like spots in the preoperative OCT en-face images may be useful to predict an ILM defect.

Point: to peel or not to peel, that is the question

Dear Editor, Macular hole with retinal detachment (MHRD) typically occurs in high myopes. The most accepted theory for its pathogenesis is that the vitreous cortex adherent to the retinal surface around the macula causes tangential traction on it causing retinal detachment along with a macular hole (MH) in staphylomatous eyes.[1–3] Electron microscopy of the surgical specimens shows the presence of myofibroblasts on internal limiting membrane (ILM), the contraction of which probably causes retinal detachment. Thus, the removal of ILM plays a pivotal role in MHRD surgery.[4] Macular buckling is a historical reversible technique used for treating MHRD, which was developed by Schepens. It acts by counteracting the pulling force caused by staphyloma. It can give both anatomical and functional outcomes. However, the placement of buckle at the correct place is difficult to achieve. Still, there has been renewed interest in the surgery recently. A newly developed suprachoroidal buckling technique uses stabilized, cross-linked, long-acting hyaluronic acid which is filled in the supra choroidal space in the area of the staphyloma so as to achieve a choroidal indenting effect.[5] Gonvers and Machemer were the first to perform pars plana vitrectomy (PPV), partial air-fluid exchange, and face-down positioning for the treatment of MHRD.[6] This technique did not give lasting results; however, advancements in the procedure made it the primary surgery for MHRD. Further studies proved that epiretinal membrane (ERM) removal alone does not relieve all the tangential traction. Seike et al.[3] achieved 50% reattachments rates with ERM removal due to recurrent membrane formation. The most popular surgery for MHRD presently is PPV with ILM peeling with intraocular tamponade. ILM peeling apparently removes all the residual vitreous cortex, ERMs, and cellular constituents but ILM peeling is difficult in such cases because the retina is mobile. Atrophic retina also makes visibility of macular hole difficult. The use of perfluorocarbon liquid facilitates ILM peeling. Modification of the surgery includes inverted ILM flap or lens capsule flap for closure of macular hole which may be assisted by an autologous blood clot, which showed better anatomical results than ILM peeling.[7,8] Endolaser to macular hole rim has also been performed but did not show significant results.[9] Gas tamponade has been found to have better retinal reattachment rates than silicone oil.[10] Ando et al.[11] used the technique of scleral imbrication in which they placed 4–5 mattress sutures in the superotemporal and inferotemporal quadrants which were then tightened, and vitrectomy with ILM was performed. This works by reducing the degree of curvature of the posterior staphyloma. Retina was attached in all patients, and 44% patients had closed macular hole. The most recent surgery for MHRD is autologous neurosensory retinal free flap closure of macular hole, first used by Grewal and Mahmoud.[12] This technique involves harvesting an autologous neurosensory retinal free flap and positioning it over the refractory MH to provide a scaffold and plug for hole closure. Several studies have been published for the same, and the reattachment rate is 88% as shown on optical coherence tomography. However, the data is small. The anatomical and visual outcomes of the above surgeries have not been promising. A study on long-term outcomes of PPV with ILM peeling or ILM flap technique, by Kim et al.,[13] showed that vision after surgery was not maintained and the closure effects were not observed at a 3-year follow-up. In another study comparing macular buckling and vitrectomy by Zhao et al.,[14] the results showed that both surgeries improved post-operative vision, but retinal reattachments rates were better by macular buckling. The pursuit for long-lasting favorable results continues. Surgery for MHRD still remains a challenge.

To examine the effect of internal limiting membrane (ILM) removal on epiretinal membrane (ERM) surgery by comparing best-corrected visual acuity (BCVA), optical coherence tomography central macular thickness (CMT) changes, ERM recurrence, and need for repeat surgery. Retrospective study of 251 consecutive patients (251 eyes) who underwent pars plana vitrectomy for idiopathic ERM by a single surgeon with over 1 year of follow-up data. Data were collected preoperatively and postoperatively at 3 months, 1 year, 2 years, and at the last visit. The ILM was not specifically removed in the earlier group of patients and was removed after staining of the ILM in the later group. One hundred and forty eyes (55.8%) did not have an ILM peel (non-ILM group), and 111 eyes (44.2%) did have an ILM peel (ILM group). There were no significant differences between groups in age, gender, preoperative BCVA, preoperative intraocular pressure, preoperative CMT on optical coherence tomography, and cataract status. Total follow-up time for the ILM group was 32.1 months and 45.4 months for the non-ILM group (P = 0.002). Both groups had improvement in BCVA. The ILM group improved by 12 Early Treatment Diabetic Retinopathy Study letters and the non-ILM group improved by 10.5 Early Treatment Diabetic Retinopathy Study letters. There was no significant difference in the final BCVA (P = 0.18) or total change of BCVA (P = 0.48). Cataract status preoperatively did not affect the total change of BCVA, but being phakic at the most recent visit was associated with a slight loss of visual acuity. Both groups had improvement in optical coherence tomography appearance, for the CMT in the ILM group decreased by 83 μm and the CMT in the non-ILM group decreased by 110 μm. There was no significant difference in the final CMT (P = 0.07); however, the non-ILM group tended to have a lower final CMT. Some degree of ERM recurrence was detected by slit-lamp biomicroscopy in 2 eyes (1.8%) of the ILM group and in 32 eyes (22.9%) of the non-ILM group (P ≤ 0.0001). None of the eyes with ILM removal required repeat vitrectomy, whereas 17 eyes (12.1%) of the non-ILM group did require vitrectomy, showing that ILM removal had a significant effect on the need for repeat vitrectomy (P < 0.0001) between non-ILM versus ILM peel groups. The rate of recurrent ERM and need for repeat ERM surgery is lower in eyes where the ILM is removed with the ERM, whereas BCVA and CMT were similar with or without ILM removal. Complete ILM removal around the macula should be considered for the treatment of eyes with idiopathic ERMs to reduce the incidence of ERM recurrences.