Prophylactic internal limiting membrane peeling during rhegmatogenous retinal detachment surgery.

Abstract

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.