Conventional Internal Limiting Membrane Peeling Research Articles

Epiretinal Membrane Surgery Using Intraoperative OCT-Guided Membrane Removal in the DISCOVER Study versus Conventional Membrane Removal

To provide a comparative assessment of clinical outcomes between patients undergoing intraoperative OCT (iOCT) and conventional surgery for pars plana vitrectomy (PPV) with epiretinal membrane (ERM) peel. Case-control retrospective, comparative assessment. Patients undergoing PPV with membrane peel for ERM with eyes pooled from the prospective Determination of Feasibility of Intraoperative Spectral Domain Microscope Combined/Integrated OCT Visualization During En Face Retinal and Ophthalmic Surgery (DISCOVER) iOCT study and eyes undergoing conventional ERM surgery without iOCT. Visual acuity and OCT assessment before ERM surgery and at 1-, 3-, 6-, and 12-month follow-up after standard small-gauge PPV with iOCT feedback (iOCT DISCOVER group) or PPV with compulsory internal limiting membrane (ILM) peeling (conventional group). Visual acuity, central subfield thickness (CST), reoperation rate, and ERM recurrence were determined by record review and post hoc assessment of clinical OCTs after ERM peel. Visual acuity and ERM recurrence. A total of 262 eyes were included. Visual acuity (VA) improved 11.9 letters in the iOCT group (P<0.0001) and 12.1 letters in the conventional group (P < 0.0001) at 12 months after ERM surgery. Visual acuity improvement did not differ between the iOCT and conventional groups at 1, 3, 6, or 12 months after surgery (P>0.05 for each time point). Preoperative mean CST decreased in the iOCT group (P < 0.0001) and conventional group (P < 0.0001) with no difference between groups in CST reduction at 12 months (P= 0.36). No reoperations or visually significant recurrent ERMs occurred in either cohort. Intraoperative OCT-guided ERM removal without mandated ILM peeling provided similar VA and anatomic results to conventional ILM peeling for ERM. Future randomized prospective studies are needed to assess fully the possible role of iOCT in ERM surgery and to evaluate the potential impact of nonfoveal ERM persistence or recurrence in comparison with conventional surgery.

Inverted Internal Limiting Membrane Flap Technique versus Internal Limiting Membrane Peeling for Large Macular Holes: A Meta-Analysis of Randomized Controlled Trials

Background: Vitrectomy with internal limiting membrane (ILM) peeling is an effective surgical procedure for the treatment of macular holes (MHs). However, there is a possibility of poor postoperative anatomical closure with conventional ILM peeling for MHs larger than 400 μm. Therefore, a novel inverted ILM flap technique was developed for such cases. Objectives: This meta-analysis study was performed to evaluate and compare the anatomical and visual outcomes of the inverted ILM flap technique and ILM peeling in large MHs. Methods: The Cochrane Library, PubMed, and Embase databases were searched to identify randomized controlled trials (RCTs). The trial eligibility and risk of bias were assessed according to Cochrane review methods. The primary outcome measures included MH closure rate and postoperative visual acuity (VA). Subgroup analysis of postoperative VA based on follow-up time was also conducted. Pooled odds ratios (ORs), weighted mean difference (WMD), and 95% confidence intervals (CIs) were calculated. Statistical analysis was performed using RevMan 5.3 software. Results: Five RCTs with a total of 155 eyes in the inverted ILM flap group and 161 eyes in the ILM peeling group were included in this meta-analysis. Statistical meta-analysis revealed that the overall MH closure rate in the inverted ILM flap group was significantly higher than that in the ILM peeling group (OR = 3.10; 95% CI: 1.25–7.66; p = 0.01). The postoperative VA was significantly better in the inverted ILM flap group than the ILM peeling group (WMD = −0.14; 95% CI: −0.21 to −0.07; p = 0.0002). The subgroup meta-analysis indicated that the postoperative VA was significantly better in the inverted ILM flap group than the ILM peeling group (WMD = −0.17; 95% CI: −0.26 to −0.08; p = 0.0004) at the 3-month follow-up. However, no significant difference was observed between the 2 groups at the 6-month follow-up (WMD = −0.09; 95% CI: −0.20 to 0.02; p = 0.10). Conclusions: Vitrectomy with the inverted ILM flap technique showed a higher anatomical closure rate as well as visual gain – although only in the short term as no difference in visual recovery was found at the 6-month follow-up – than did ILM peeling in large MHs. The inverted ILM flap technique should be considered as a preferred and routine procedure for the treatment of patients with MHs larger than 400 µm.

Comparative study of 1 DD and 2 DD radius conventional internal limiting membrane peeling in large idiopathic full-thickness macular holes: a randomized controlled trial.

To compare the surgical outcomes of 1-disc diameter (DD) and 2-DD conventional internal limiting membrane peeling (C-ILMP) in large full-thickness macular holes (FTMHs). A prospective randomized controlled trial. One hundred patients with large idiopathic full-thickness macular hole (FTMH) were randomized into C-ILMP and extended C-ILMP (EC-ILMP) groups. The primary outcome was closure rate at 6 months after surgery. Secondary outcomes were visual acuity (VA), closure type, consequence of ILMP and complications. The mean symptom duration was 12.19 ± 9.64 months. Mean preoperative VA was 1.25 ± 0.37 logMAR. The average minimum linear diameter was 633.05 ± 129.82 µm and basal linear dimension was 1158.49 ± 249.07 µm. The two groups did not differ in term of demographic data. Closure rate was significantly higher in the EC-ILMP group (76.47% vs. 51.02%, 95% CI 7.24-43.66; p = 0.008). There were also no significant differences in closure type, central foveal thickness, dissociated optic nerve fibre layer detection, or change in fovea-to-disc distance. There were also no significant differences in postoperative VA (p = 0.069) or visual improvement (mean 0.39 ± 0.43 logMAR; p = 0.286). According to subgroup analysis, EC-ILMP resulted in a higher closure rate in patients with chronic FTMH for >6 months, (p = 0.008). Furthermore, EC-ILMP resulted in better anatomical closure and visual result in patients with FTMH with macular hole closure index ≤0.5, p = 0.003 and p = 0.010, respectively. Extended C-ILMP yielded a significantly higher closure rate in large FTMHs, but visual outcome did not differ significantly. According to subgroup analysis, extended C-ILMP was more effective in chronic large FTMH with MHCI ≤ 0.5.

Large macular hole-Always a poor prognosis?

HintergrundAlter, präoperativer Visus und Makulaforamengröße gelten als prognostische Marker für das postoperative Ergebnis bei Patienten mit durchgreifendem Makulaforamen (MF).Ziel der ArbeitUm den postoperativen Verlauf nach i‑ILM Peeling (inverted-Flap ILM-Peeling) mit konventionellem ILM-Peeling (k-ILM) zu vergleichen, wurde eine retrospektive Beobachtungsstudie durchgeführt. Patienten mit i‑ILM Peeling hatten dabei präoperativ ein statistisch signifikant größeres Makulaforamen.Material und MethodenEs wurden 45 konsekutive Patienten mit durchgreifendem Makulaforamen (MF) in 2 Gruppen (i-ILM vs. k‑ILM) eingeteilt und auf Unterschiede im postoperativen Visus (BCVA) und der Netzhautmorphologie hin untersucht. Die Integrität der äußeren Netzhautschichten, äußere limitierende Membran (ELM), ellipsoide Zone (EZ) und äußere Photorezeptoraußensegmente (OS), wurde postoperativ mittels SD-OCT (Spectral-Domain-OCT) analysiert.ErgebnisseDie präoperative Apertur in der i‑ILM Gruppe war signifikant größer (i-ILM = 408,4 µm, SD = 157,5 µm; k‑ILM = 287,4 µm, SD = 104,9 µm; p = 0,01). Der Ausgangsvisus sowie der postoperative Visus nach 1 Monat waren in der Gruppe mit k‑ILM-Peeling signifikant besser (p = 0,03 und p = 0,001). Der postoperative Visus nach mindestens 6 Monaten zeigte keinen signifikanten Unterschied zwischen den beiden Gruppen (p = 0,24). Die ELM zeigte als erste der äußeren Netzhautschichten eine Re-Integrität in beiden Gruppen.SchlussfolgerungMithilfe der i‑ILM-Peeling-Technik erschien es in dieser konsekutiven Serie möglich zu sein, für Patienten mit großem durchgreifendem MF ein ähnliches postoperatives Visusergebnis zur erreichen wie für mittels k‑ILM-Peeling-Technik operierte Patienten mit kleinerem durchgreifendem MF.

EFFECT OF INVERTED INTERNAL LIMITING MEMBRANE FLAP ON CLOSURE RATE, POSTOPERATIVE VISUAL ACUITY, AND RESTORATION OF OUTER RETINAL LAYERS IN PRIMARY IDIOPATHIC MACULAR HOLE SURGERY.

To investigate the role of an internal limiting membrane (ILM) flap in macular hole (MH) surgery on closure rate, visual acuity, and integrity of the outer retinal layers. Retrospective, nonrandomized interventional analysis in which 117 eyes of 117 patients were included who had undergone pars-plana vitrectomy (PPV) and gas tamponade for primary idiopathic MH >400 µm with either conventional ILM peeling or with inverted ILM flap technique at The Royal Liverpool University Hospital between January 2016 and April 2018. Main outcome measures were closure of MH, best-corrected visual acuity (BCVA) at 3, 6, and 12 months, and restoration of external limiting membrane and ellipsoid zone (EZ) using optical coherence tomography. Macular hole closure rate was significantly higher in patients with an ILM flap (67/68; 98.53%) than in those with conventional ILM peeling (43/49; 87.76%) (P = 0.02). Both groups showed significant improvements in their preoperative to postoperative BCVA at 3 months from 1.07 (0.43) logarithm of the minimum angle of resolution (logMAR) (20/235 Snellen) to 0.71 (0.34) logMAR (20/103 Snellen) (P <0.001), but there was no significant difference between the two groups (P = 0.45, P = 0.71). We found significant associations between postoperative BCVA and preoperative BCVA (P < 0.01) and the integrity of the EZ (P < 0.01). In 35 patients who had follow-up to 12 months, there was a significant improvement in BCVA between 3, 6, and 12 months from 0.73 (0.45) logMAR (20/107 Snellen) to 0.53 (0.24) logMAR (20/68 Snellen) and to 0.35 (0.18) logMAR (20/45 Snellen), respectively (P < 0.01). There was no significant difference at these time periods between the two groups (P = 0.62, P = 0.21, P = 0.31). The integrity of the EZ also improved significantly between 3, 6, and 12 months (P = 0.01), irrespective of the presence of an ILM flap (P = 0.58), but with a trend toward delay in restoration in those patients with an ILM flap. The improvement in BCVA at 12 months, taking into account the age of the patient, size and duration of the MH, presence of an ILM flap, and preoperative BCVA was dependent on the state of the EZ (P = 0.01). In patients undergoing primary pars-plana vitrectomy for MH >400 µm, the presence of an inverted ILM flap was associated with a significantly higher closure rate than a conventional ILM peeling. Best-corrected visual acuity showed a strong correlation with the integrity of the EZ and both improved significantly between 3, 6, and 12 months, irrespective of the presence of an ILM flap.

SURGICAL OUTCOMES AFTER INVERTED INTERNAL LIMITING MEMBRANE FLAP VERSUS CONVENTIONAL PEELING FOR VERY LARGE MACULAR HOLES

To evaluate the anatomical and visual outcomes of inverted flap technique of peeling of internal limiting membrane (ILM) versus standard peeling of ILM for macular holes of basal diameter more than 800 μm. Patients with very large idiopathic macular holes more than 800 μm in basal diameter (ranging from 243 μm to 840 μm in minimum diameter) were retrospectively included in the study. In Group A, 18 eyes of 18 patients underwent ILM peeling using the inverted flap technique. In Group B, 18 eyes of 18 patients underwent conventional ILM peeling. The primary endpoint was the rate of hole closure at 6 months after surgery. The secondary outcome measure was the change in best-corrected visual acuity at 6 months after surgery. There were no significant differences in ocular characteristics of the study groups at baseline except for the age distribution. Mean macular hole diameter was 1,162.8 ± 206.0 μm and 1,229.6 ± 228.1 μm in Group A and Group B, respectively. The hole closure rate was 88.9% (16/18) in Group A and 77.8% (14/18) in Group B (P = 0.66). The mean gain in best-corrected visual acuity was higher in Group A than in Group B (P = 0.12) at 6 months, but this was not statistically significant. There were no severe ocular adverse events in either group. In this multicenter series, inverted ILM flap technique did not lead to significantly higher anatomical closure rates than conventional ILM peeling in large macular holes more than 800 μm in diameter.

Surgical results of internal limiting membrane flap inversion and internal limiting membrane peeling for macular hole.

PurposeThe internal limiting membrane (ILM) is a normal part of the retina, and the outcomes of ILM removal have not been fully investigated. ILM flap inversion is a recently developed technique that increases the success rate of macular hole (MH) surgery. Thus, we compared the anatomical closure rate and visual outcome in patients undergoing microincision vitrectomy surgery (MIVS) with ILM flap inversion or conventional ILM peeling for the treatment of MH.MethodsThe medical records of 90 eyes with MH were reviewed retrospectively. The patients were classified into two groups based on MIVS procedure (group 1: ILM flap inversion, 46 eyes; group 2: ILM peeling, 44 eyes).ResultsPreoperative characteristics were similar in the two groups, and there were no significant differences in 1 month- or 6 month-postoperative VA between the groups (P = 0.25 and P = 0.42, respectively). However, the surgical success rate was significantly higher in group 1 than group 2 (P = 0.04; 46/46: 100% and 41/44: 93%, respectively). Multiple regression analysis revealed that axial length and MH diameter were independent factors predicting 6-month postoperative BCVA in group 2 (P = 0.001 and P = 0.03, respectively), and that MH diameter was an independent factor predicting 6-month postoperative VA in group 1 (P = 0.03). Logistic regression analysis revealed that axial length (OR = 2.11; P = 0.02; area under the curve: 0.94; cut off score: 28.4 mm) was an independent factor indicating surgical failure in group 2.ConclusionOur results suggest that MIVS with ILM flap inversion might be best suited to treat MH, particularly in patients with high myopia.

Best surgical technique and outcomes for large macular holes: retrospective multicentre study in Japan.

The purpose of this study was to compare the surgical outcomes of vitrectomy with conventional internal limiting membrane (C-ILM) peeling to that with the inverted ILM (I-ILM) flap technique for large macular holes (MHs). This was a retrospective chart review of consecutive cases with a large MH at nine hospitals in Japan. Among the 1342 eyes, 165 eyes of 165 cases met the inclusion criteria. The results for medium-large MHs with a diameter 400-550μm were compared to that of eyes with an extra-large MH with a diameter >550μm. In addition, the results of C-ILM peeling were compared to that of the I-ILM technique. In medium-large MHs, the closure rate was 95.2% (59/62) by C-ILM peeling and 100% (19/19) by the I-ILM technique. In extra-large MHs, the closure rate was 88.4% (38/43) by C-ILM peeling and 100% (41/41) by I-ILM. Although the difference between the two methods was not significant, the I-ILM technique was successful in 100% of the cases. Multiple logistic regression analysis showed the best-corrected visual acuity (BCVA) at 6months was significantly associated with the preoperative BCVA, MH size, age and sex of the patient. Analyses of the eyes with extra-large MHs show that the surgical success is high, and the I-ILM technique is more effective for closure in eyes with extra-large MHs.

Inverted ILM flap, free ILM flap and conventional ILM peeling for large macular holes

BackgroundTo assess closure rate after a single surgery of large macular holes and their visual recovery in the short term with three different surgical techniques.MethodsProspective multicenter randomized controlled trial. We included treatment-naïve patients with diagnosis of large macular hole (minimum diameter of > 400 µm). All patients underwent a comprehensive ophthalmological examination. Before surgery, the patients were randomized into three groups: group A: conventional internal limiting membrane peeling, group B: inverted-flap technique and group C: free-flap technique. All study measurements were repeated within the period of 1 and 3 months after surgery. Continuous variables were assessed with a Kruskal–Wallis test, change in visual acuity was assessed with analysis of variance for repeated measurements with a Bonferroni correction for statistical significance.ResultsThirty-eight patients were enrolled (group A: 12, group B: 12, group C: 14). The closure rate was in group A and B: 91.6%; 95% CI 61.52–99.79%. In group C: 85.71%; 95% CI 57.19–98.22%. There were no differences in the macular hole closure rate between groups (p = 0.85). All groups improved ≈ 0.2 logMAR, but only group B reached statistical significance (p < 0.007).ConclusionsDespite all techniques displayed a trend toward visual improvement, the inverted-flap technique seems to induce a faster and more significant recovery in the short term.

Direct transretinal removal of subfoveal perfluorocarbon liquid: the role and timing of internal limiting membrane peeling.

To describe a case series including 4 patients undergoing direct transretinal aspiration of subfoveal perfluorocarbon liquid (PFCL) and internal limiting membrane (ILM) peeling after macula-off retinal detachment surgery. Four patients who had undergone vitreoretinal surgery due to primary rhegmatogenous retinal detachment were further treated because of retained subfoveal PFCL. Direct transretinal aspiration of PFCL through a self-sealing foveal retinotomy was performed in all cases using a 41-G needle placed on the top of the bubble. The ILM was peeled off prior to and after PFCL removal in 2 cases, respectively. Optical coherence tomography (OCT) scans were obtained preoperatively and postoperatively to assess the status of the macula. Subfoveal PFCL was successfully removed in all cases. Two patients had silicone oil tamponade at the time of the second surgery, which was temporarily removed in both cases and then reapplied in one. Best-corrected visual acuity improved in all cases. No postoperative macular hole was observed by OCT. Direct transretinal aspiration of subfoveal PFCL with a 41-G cannula combined with conventional ILM peeling is a safe and effective technique to avoid long-term damage to the retinal layers with good functional outcomes. Performing the ILM peeling immediately before or after the PFCL aspiration does not seem to influence anatomic results.

EVALUATION OF THE INTERNAL LIMITING MEMBRANE AFTER CONVENTIONAL PEELING DURING MACULAR HOLE SURGERY

We evaluated the histologic features of the internal limiting membrane (ILM) of the retina removed during macular hole surgery without indocyanine green staining. Our investigation focused on the presence or absence of retinal structures adherent to the retinal surface of the ILM. Because only tiny retinal cellular fragments were observed especially in ILM folds, we conclude that conventional ILM peeling can be performed safely with a cleavage plane between the retinal surface of the ILM and Müller cell endfeet.