Modern approaches to ILM peeling in macular hole and epiretinal membrane surgery: benefits, risks, and surgical innovations

In Brief Purpose: To report the use of the dye brilliant blue G (BBG) for staining of the internal limiting membrane (ILM) during macular hole (MH) and epiretinal membrane (ERM) surgery. Methods: This study was designed as an interventional, noncomparative, prospective, clinical case series. Twenty eyes from 20 consecutive patients with MH or ERM underwent BBG-assisted ILM and ERM removal. In MH cases, a posterior vitreous detachment was created, followed by the injection of 0.25 mg/mL BBG solution into the vitreous cavity and immediate washout of the BBG. This technique improved visualization of the ILM, enabling peeling and surgery to be performed successfully. However, in ERM cases, staining of the ERM could not be confirmed at this concentration. Finally, the ILM including the ERM was removed in all cases. Preoperative and postoperative ophthalmic examinations were performed. Results: Postoperatively, 17 patients (85%) had visual acuity improved by at least 2 Snellen lines. No adverse effects were observed postoperatively during the observation period (mean follow-up ± SD, 7.3 ± 1.0 months). Conclusions: BBG selectively stains the ILM. This technique can facilitate the management of MH and ERM surgery without any adverse effects, as was shown in this short-term study. Brilliant blue G selectively stains the internal limiting membrane. This technique can facilitate the management of macular hole and epiretinal membrane surgery without any adverse effects.

Indocyanine green (ICG) dye has been used to stain the retinal internal limiting membrane (ILM) and facilitate its removal in macular hole and epiretinal membrane (ERM) surgeries.1,2 In our previous...

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

PurposeThe aim of this study was to report the intraoperative and postoperative complications of vitrectomy for epiretinal membrane (ERM) and macular hole (MH) performed by retinal fellows under direct faculty supervision compared with experienced faculty members.Patients and MethodsA total of 271 eyes that underwent pars plana vitrectomy (PPV) for MH and ERM from January 2014 to December 2019 at King Khaled Eye Specialist Hospital were analyzed. PPV for ERM and MH was performed by vitreoretinal fellows and consultants.ResultsThe outcome measures assessed were the intraoperative complications rates, such as posterior lens touch, retinal breaks (RBs), retinal detachments, and vitreous hemorrhage. Moreover, the postoperative complications and optical coherence tomography (OCT) changes were assessed upon a minimum follow-up of 6 months. The rate of iatrogenic RB was more common in the ERM than in the MH surgery (15.5% vs 11.2%). Fellows and consultants had a rate of 20.5% of RB during the ERM surgery and 14.6% during MH surgery, respectively. However, these differences were not statistically significant (p = 0.12 for MH and p = 0.236 for ERM). Postoperative OCT analysis revealed an MH closure rate of 72.2%, and complete removal of the ERM was achieved in 88.6% in cases performed by fellows, while consultants achieved 61.8% closure rate of MH, and 83.3% of the patients achieved complete removal of ERM.ConclusionMacular surgery is overall a safe procedure and the complication rates between fellows and consultants are comparable. With proper supervision, vitreoretinal fellows can achieve equally high anatomical outcomes with few complications.

Intérêt de la microscopie confocale in vitro dans l’étude des membranes épirétiniennes et des membranes limitantes internes après chirurgie maculaire

Intraoperative Microscope-Mounted Spectral Domain Optical Coherence Tomography for Evaluation of Retinal Anatomy during Macular Surgery

PurposeTo examine the incidence of pars plana vitrectomy (PPV) for full‐thickness macular hole (FTMH), epiretinal membrane (ERM) and floaters over time and across regions in Denmark.MethodsThis nationwide registry‐based study included all patients undergoing PPV for FTMH, ERM, or floaters in Denmark from 2010 to 2023. Crude and age‐standardized incidence rates were calculated using Poisson regression, stratified by sex, age, region and year.ResultsAmong 11 693 patients undergoing PPV, the median age was 71 years (IQR, 66–76) and 83% (9744/11 693) were pseudophakic at surgery. Overall incidence rates per 100 000 person‐years were 5.7 (95% CI, 5.5–5.8) for FTMH, 7.1 (6.9–7.2) for ERM, and 1.8 (1.7–1.9) for floaters. FTMH surgery was more common in females across all ages, while ERM and floater surgeries were more frequent in males aged ≥60 years. From 2010–2012 to 2021–2023, the incidence increased for FTMH and ERM, while floater surgery declined in females and remained stable in males. Regional variation was observed for all indications, most notably for ERM.ConclusionThe incidence of PPV for both FTMH and ERM rose significantly from 2010 to 2023. The regional variation in FTMH may indicate undertreatment, while differences in ERM and floater surgeries reflect the absence of standardized guidelines for ERM and floater surgery, underscoring the need for national guidelines to ensure equitable ophthalmic care.

The intravitreal application of the novel dye, brilliant blue G (BBG), has recently been suggested to facilitate macular hole and epiretinal membrane surgery because BBG has been shown to selectively...

Pars plana vitrectomy and inner limiting membrane (ILM) peeling are standard procedures for macular hole and epiretinal membrane surgery. However, ILM peeling is known to cause mechanical traumatic changes to the retinal nerve fiber layer. Recently there have been numerous reports of anatomical changes in the macula after ILM removal. A comprehensive review of the literature. The earliest change in the macula after ILM peeling is post-operative swelling of the arcuate retinal nerve fiber layer (SANFL), which disappears within the 3 month; the swelling is not detected on biomicroscopic fundus examination but appears as hypoautofluorescent arcuate striae in the macular region on infrared and autofluorescence imaging, with corresponding hyperreflectant swelling demonstrated on spectral-domain optical coherence tomography (OCT). SANFL is followed by dissociated optic nerve fiber layer defect, faintly visible on fundus examination and corresponding on OCT to "dimples" in the inner retinal layers. The en face tomographic aspect of this defect appears as concentric macular dark spots. Post-operative foveal displacement toward the optic disc might be responsible for the stretching and thinning of the retinal parenchyma in the temporal subfield and the thickening of the nasal macula. This shortening of the papillofoveal distance after surgery is probably secondary to axonal transport and contractility alterations in the nerve fiber layer, which might also account for apoptotic and atrophic degeneration of the peripapillary retinal nerve fiber layer. Ganglion cells do not seem to be affected by ILM peeling, even if the ganglion cell complex loses some volume because of trauma to the Müller cells contained in the ganglion cell layer. Despite its clear indication in macular hole and epiretinal membrane surgery, ILM peeling is a traumatic procedure that has acute effects on the underlying inner retinal layers. Further investigation of these subclinical changes may assist in aiding the development of minimally traumatic techniques for ILM removal.

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.

Macular hole surgery with internal-limiting membrane peeling and intravitreous air

Introduction: We report a case of acute macular hole (MH) formation that occurred immediately following posterior vitreous detachment (PVD) induction during epiretinal membrane (ERM) surgery, and to highlight the significance of intraoperative foveal hemorrhage as an early indicator of this complication. Case Presentation: A 47-year-old Asian female presented with blurred vision in the left eye. Preoperative examination revealed an ERM with associated macular distortion. The patient underwent cataract surgery combined with pars plana vitrectomy, including induction of PVD, ERM, and internal limiting membrane peeling. A small foveal hemorrhage was noted immediately after PVD induction. On postoperative day 1, OCT revealed a full-thickness MH with foveal hyperreflective lesion and posterior shadowing, consistent with foveal hemorrhage. Despite in-office intravitreal gas injection, the MH persisted and required a second vitrectomy with additional gas tamponade. Follow-up OCT confirmed successful closure of the MH, with gradual restoration of the photoreceptor and outer plexiform layers. Conclusion: Acute MH formation can occur immediately after PVD induction during ERM surgery, even in the absence of overt vitreomacular traction or direct macular trauma. Intraoperative foveal hemorrhage should alert the surgeon to the possibility of impending MH formation.

To report the use of the dye brilliant blue G (BBG) for staining of the internal limiting membrane (ILM) during macular hole (MH) and epiretinal membrane (ERM) surgery. This study was designed as an interventional, noncomparative, prospective, clinical case series. Twenty eyes from 20 consecutive patients with MH or ERM underwent BBG-assisted ILM and ERM removal. In MH cases, a posterior vitreous detachment was created, followed by the injection of 0.25 mg/mL BBG solution into the vitreous cavity and immediate washout of the BBG. This technique improved visualization of the ILM, enabling peeling and surgery to be performed successfully. However, in ERM cases, staining of the ERM could not be confirmed at this concentration. Finally, the ILM including the ERM was removed in all cases. Preoperative and postoperative ophthalmic examinations were performed. Postoperatively, 17 patients (85%) had visual acuity improved by at least 2 Snellen lines. No adverse effects were observed postoperatively during the observation period (mean follow-up +/- SD, 7.3 +/- 1.0 months). BBG selectively stains the ILM. This technique can facilitate the management of MH and ERM surgery without any adverse effects, as was shown in this short-term study.

Background: The role of PCLR in vitrectomy surgeries for macular diseases is controversial. Several studies report a reduction in post-operative RD rates, while other studies do not show such reduction. reducing complications stemming from intra- and post- operative retinal tears, especially at sclerotomy sites, are suggested as reasons for PCLR use. Objective: To investigate the effect of PCLR on the rate of post-operative RD in patients undergoing pars plana vitrectomy for either Macular Hole (MH) or epiretinal membrane (ERM). Methods: This retrospective study included 179 eyes of 170 patients who underwent vitrectomy for either MH or ERM between 2006-2012. Recorded parameters included demographic information, diagnosis, lens status, use and type of tamponade, whether PCLR was performed, follow-up period, the occurrence of RD, the cause and time of RD. Outcome and complication rates were compared between patients who received PCLR (PCLR group) and those who did not (Control group). Results: The study included 179 eyes of 170 patients. 126 eyes had PCLR while 53 eyes did not. Pre-operative demographics data, best-corrected visual acuity, lens status and indication for macular surgery were similar between the two groups. Post-operative RD was diagnosed in one eye (1.8%) in the control group and 5 eyes (3.9%) in the PCLR group (Kaplan-Meier survival analysis, log-rank p = 0.28). Conclusion: PCLR was not correlated with a decrease in RD in MH and ERM surgeries in our cohort. Intra-operative and post-operative examination for small retinal breaks is essential in all surgeries. PCLR might be unnecessary in small gauge vitrectomies.

The purpose of this study was to evaluate the incidence of retinal detachment (RD) after a small-incision, sutureless vitrectomy compared with conventional 20-gauge vitrectomy in macular hole and epiretinal membrane surgery and to investigate the clinical features and possible causative agents. The authors performed a computerized database analysis to retrospectively identify all patients who underwent vitrectomy at our institution between March 2001 and March 2009 for epiretinal membrane and macular hole. The authors further investigated the clinical features of patients who showed RD within 6 months postoperatively in the study eye. The incidence rate and clinical features of the affected eyes were analyzed. During the study period, 2,432 vitrectomies were performed for epiretinal membrane and macular hole. The incidence of RD was 1.7% (31 of 1,862) after sutureless 25- or 23-gauge vitrectomy and 1.2% (7 of 570) after conventional 20-gauge vitrectomy. The difference was not statistically significant. Moreover, the difference between 25-gauge surgery (28 of 1,580) and 23-gauge surgery (3 of 282) was not statistically significant. In 9 of 38 cases (24%), the RD was probably attributable to the underlying pathology (e.g., an unclosed macular hole and reopening of preexisting retinal tears). Twenty-one eyes (76%) presented new retinal tears that were not related to the sclerotomies in both groups. The incidence of RD after macular surgery is not increased in small-gauge, sutureless vitrectomy compared with the standard 20-gauge procedure. In most cases, the RD is not caused by the surgical technique itself but caused by new retinal breaks.