Internal Limiting Membrane Removal Research Articles

RANDOMIZED TRIAL COMPARING MICROSERRATED VERSUS CONVENTIONAL INTERNAL LIMITING MEMBRANE FORCEPS FOR INTERNAL LIMITING MEMBRANE PEELING.

To evaluate anatomic outcomes and surgeon response following the use of microserrated (Sharkskin, Alcon, Forth Worth, TX) internal limiting membrane (ILM) forceps compared with conventional (Grieshaber; Alcon) ILM forceps for peeling of the ILM. Patients were prospectively assigned in a 1:1 randomized fashion to undergo ILM peeling using microserrated forceps or conventional forceps. Rates of retinal hemorrhages, deep retinal grasps, ILM regrasping, time to ILM removal, and surgeon questionnaire comparing the use of microserrated and conventional ILM forceps were analyzed. A total of 90 eyes of 90 patients were included in this study. The mean number of deep retinal grasps was higher in the conventional forceps group (1.51 ± 1.70 vs. 0.33 ± 0.56, respectively [P < 0.0001]). The mean number of failed ILM grasps was higher with conventional forceps (6.62 ± 3.51 vs. 5.18 ± 2.06 [P = 0.019]). Microserrated forceps provided more comfortability (lower number) in initiating the ILM flap (2.16 ± 0.85 vs. 1.56 ± 0.76, P < 0.001), comfortability in regrasping the ILM flap (2.51 ± 1.01 vs. 1.98 ± 0.89, P = 0.01), and comfortability in completing the ILM flap (2.42 ± 1.03 vs. 1.84 ± 1.02, P = 0.01). Surgeons utilizing the microserrated forceps experienced fewer deep retina grasps and fewer failed ILM grasps compared with conventional ILM forceps. The microserrated forceps was also a more favorable experience subjectively among the surgeons.

Clinical observation of the intraocular distribution characteristics of indocyanine green after epiretinal membrane peeling using a fluorescence detection system developed in Python

Objective: To utilize a Python-based fluorescence area detection system to observe and quantitatively analyze the intraocular distribution characteristics and metabolic patterns of Indocyanine Green (ICG) following epiretinal membrane peeling. Methods: A prospective case series study was conducted on patients with idiopathic epiretinal membrane undergoing vitrectomy at West China Hospital of Sichuan University from March 2019 to March 2021. ICG staining was applied during surgery for peeling the epiretinal membrane and internal limiting membrane. Patients were followed up at 1 week, 1 month, 3 months, 6 months, and 12 months postoperatively, with assessments including best-corrected visual acuity, intraocular pressure, fundus photography, near-infrared fundus fluorescence imaging (NIR-FF), and optical coherence tomography (OCT). A Python-based ICG intraocular metabolism detection system was developed to measure the residual area of ICG fluorescence on NIR-FF, predict the ICG metabolic pattern equation, and correlate it with postoperative visual acuity and peripapillary retinal nerve fiber layer thickness. Results: A total of 64 patients (64 eyes) were included, with an average age of 64.6±8.4 years, including 25 males (39.1%) and 39 females (60.9%). Preoperative NIR-FF images showed no ICG strong fluorescence. At 1 week postoperatively, diffuse ICG strong fluorescence appeared in the posterior pole, and the internal limiting membrane removal area exhibited a ring-like weak fluorescence. Over time, ICG strong fluorescence was observed along the vascular arch and nerve fiber trajectory, gradually diminishing toward the optic disc, with residual ICG fluorescence still visible at the optic disc at 1 year. The Python-based ICG fluorescence area detection system effectively measured intraocular residual ICG area. A predictive equation for the 12-month residual ICG area was constructed through linear regression analysis (Residual ICG area=0.22 × Residual ICG area at 6 months, R2=16%, P=0.002). Except for a negative correlation between the ICG residual area at 1 month and postoperative visual acuity (P=0.017, r=-0.195), no correlation was found between intraocular ICG fluorescence residual area and postoperative visual acuity or peripapillary retinal nerve fiber layer thickness at other follow-up times (all P>0.05). Conclusions: In patients with idiopathic epiretinal membrane undergoing ICG staining for internal limiting membrane peeling, ICG exhibits characteristic metabolic processes in the eye, with strong fluorescence along the vascular arch and nerve fiber trajectory, gradually converging toward the optic disc over time. The Python-based ICG fluorescence area detection system provides a clear display of the intraocular distribution characteristics of ICG after epiretinal membrane peeling and serves as a tool for predicting the metabolic patterns of ICG in the eye.

Long-Term Outcomes of Vitrectomy for Idiopathic Epiretinal Membrane With Internal Limiting Membrane Removal in Patients With Good Preoperative Visual Acuity.

Purpose: To evaluate the long-term visual results of vitrectomy with epiretinal membrane (ERM) and internal limiting membrane (ILM) removal for idiopathic ERM in eyes with a preoperative visual acuity (VA) of 20/50 or better. Methods: This retrospective review of a consecutive case series comprised 337 patients. Of these, 36 eyes of 36 patients had ERM and ILM removal from 2017 to 2018. Inclusion criteria included a subjective decrease in VA, a preoperative VA of 20/50 or better, vitrectomy with ERM and ILM removal for ERM, and a minimum 6-month follow-up. Paired t tests were used to determine the statistical significance (P < .05) of VA changes postoperatively. Results: The mean (±SD) best-corrected logMAR VA improved to a maximum of 0.125 ± 0.09 (Snellen equivalent 20/26.4) at a mean of 11.1 months postoperatively (P < .001). The VA continued to significantly improve over the long term (mean, 41.6 months; range, 6-63; P < .001). Overall long-term data trended heavily toward VA improvement (25/36 patients [69.4%]) and stability (10/36 patients [27.7%)] after ERM and ILM removal, with only 1 patient (2.8%) having worse VA. There were no intraoperative or postoperative complications related to ERM and ILM removal. Conclusions: Surgery to remove idiopathic ERM and ILM for patients with significant symptoms and good preoperative VA may result in excellent long-term visual results.

Selective ILM Staining and Safety of Two Vital Dyes During a Human-Like Pars Plana Vitrectomy Ex Vivo in Porcine Eyes

Purpose An ideal dye for intraocular use should effectively stain the target tissue while being easy to apply and remove. Additionally, it should not have any adverse effects resulting from prolonged contact with the retinal tissue. Recently, concerns have been raised about the safety of some vital dyes during surgical procedures as they may cross the internal limiting membrane and deposit on the retina. In this study, we aimed to investigate whether commercially available vital dyes, VIEW-ILM® and TWIN® (AL.CHI.MI.A. S.r.l., Ponte San Nicolò, Padova, Italy), have the potential to cross the internal limiting membrane during vitreoretinal surgery and deposit on the retina. Furthermore, we evaluated their safety in vitro and in vivo. Methods A human-like pars plana vitrectomy was performed on porcine eyes ex vivo, with VIEW-ILM® or TWIN® used to stain the internal limiting membrane either with or without subsequent internal limiting membrane peeling. The two dyes were then extracted from retinal punches with or without internal limiting membrane, and quantified using high performance liquid chromatography. Safety was evaluated through in vitro cytotoxicity tests and in vivo skin sensitization and irritation tests according to ISO standards. Results High performance liquid chromatography analyses demonstrated that VIEW-ILM® and TWIN® effectively stained the internal limiting membrane without crossing the membrane. No residual dyes were found in the retinal layers after internal limiting membrane removal. Furthermore, both in vitro and in vivo safety tests confirmed the absence of cytotoxicity, skin sensitization, and irritation. Conclusion The results of this study support the safety and efficacy of VIEW-ILM® and TWIN® for internal limiting membrane staining. The experimental protocol described in this study could be utilized to gain a comprehensive understanding of the characteristics of vital dyes.

Pars Plana Vitrectomy for Proliferative Diabetic Retinopathy With and Without Internal Limiting Membrane Peeling: A Case Series

Introduction : Proliferative Diabetic Retinopathy (PDR) is a potentially blinding complication of diabetes mellitus, one of them because of tractional retinal detachment. Pars Plana Vitrectomy (PPV) is performed to treat it and in recent years internal limiting membrane (ILM) peeling has been employed as an additional treatment for patient with PDR.&#x0D; Case Illustration : Two patient, patient 1 (male, 64 years old) was diagnosed with right eye vitreous hemorrhage due to high-risk PDR and left eye vitreous hemorrhage due to early PDR + DME, and patient 2 (female, 58 years old) was diagnosed with right and left eye PDR + ERM + senile immature cataract. Both patients underwent PPV + membrane peeling + endolaser for both eyes, and additional ILM peeling on their left eye. The visual acuity 1 month after surgery without ILM peeling on right eye was improved to 6/30 and 6/18, and with ILM peeling on left eye was improved to 6/30 for both patients.&#x0D; Discussion : Removal of the ERM either with or without ILM peeling can significantly improve vision. However, many other comparison studies found no functional difference between both groups. In addition, one study found ILM removal was correlated with worse visual outcome. In this study, visual acuity 1 month after surgery in both with and without ILM peeling was improved compared with pre- operative.&#x0D; Conclusion : Although there are still pros and cons, PPV with additional ILM peeling gives results as good as PPV without ILM peeling for patient with PDR.

Comparison of Techniques: Inverted Flap and Conventional Internal Limiting Membrane Removal in Idiopathic Macular Hole Surgery

To compare functional and anatomical outcomes between the inverted flap technique and conventional removal of the internal limiting membrane (ILM) in the surgical management of idiopathic macular hole (IMH). We retrospectively evaluated the anatomical and functional results in 67 eyes of 65 patients operated on for IMH. The patients were operated on either using the conventional ILM peeling technique (first group) or with the inverted ILM flap technique (second group). 43 eyes of 41 patients were included in the first group, 24 eyes of 24 patients in the second group. We indicated for surgery only patients with IMH stage 2-4 according to the Gasse classification. Best corrected visual acuity (VA) was always determined before and two months after surgery. Furthermore, a comparison of both techniques was made according to the average letter gain after surgery, and the effect of surgery was evaluated using OCT with regard to whether IMH closure succeeded. For both techniques, 25G PPV with SF6 tamponade was performed. Hole closure took place in 41 eyes with conventional ILM removal. In one eye, the hole did not close even after reoperation with the same technique. Median ETDRS letter gain was 7.0. VA remained the same in 2 eyes (4.7%), worsened in 7 cases (16.2%), and improved in all other cases (79.0%). In 16 eyes (37.2%), VA improved by 2 or more lines of ETDRS charts. Using the inverted flap technique, the hole was closed in all 24 monitored eyes. Median ETDRS letter gain was 9.5. VA remained the same in 2 eyes (8.3%), worsened in 2 cases (8.3%), and improved in all other cases (83.3%). In 12 eyes (50.0%), VA improved by 2 or more lines of ETDRS charts. There were no serious complications intraoperatively or postoperatively. Our study demonstrated the safety and efficacy of both methods. Although the results were not statistically significant, the inverted flap technique recorded a greater ETDRS letter gain (9.5 vs. 7.0) and proportion of closed holes (100% vs. 95.3%) compared to the conventional ILM peeling technique in our set of eyes.

Surgical Treatment of Epiretinal Membranes: a Comparative Analysis of Various Removal Techniques.

In most cases, vitreoretinal surgery is the only way to treat epiretinal membrane (ERM). For a long time, surgeons only removed epiretinal fibrosis. But relapse of ERM took place in 10% of cases. Internal limiting membrane (ILM) peeling reduced the number of relapses, but this membrane is connected closely with terminal legs of Müller cells and its removal leads to mechanical and functional damage of the latter. In addition, frequent cases of "dissociation of the optic nerve fiber layer" were noticed in the long term after ILM removal, which caused a deterioration in the functional state of the retina. Purpose. The purpose of study was to conduct a comparative analysis of various methods of surgical treatment of epiretinal membrane. Materials and methods. On the base of the National Medical Center of Ophthalmology 75 patients with epiretinal membrane were treated with vitreoretinal surgery. All patients were divided into 3 groups. Patients of the first group were operated according to the standard procedure with the removal both ERM and ILM. The second group included patients after ERM removal without ILM peeling. The third group of patients were operated according to the original method – after ERM removal specific "debilitating notches" were performed on ILM. A complete ophthalmological examination was conducted for all patients in the pre- and postoperative period (1,3,6,12 months after surgical treatment). There were no significant differences between groups in age, gender, preoperative BCVA, preoperative intraocular pressure, preoperative CMT on optical coherence tomography, and cataract status. Results. Analysis of the results in the postoperative period revealed a significant improvement in BCVA at 6 months after surgery in the 2nd and 3rd groups of patients in comparison to the 1st group of patients. Assessment of morphological parameters of the retina in the postoperative period showed a significant improvement of condition in epiretinal fibrosis in groups 2 and 3 at 6 and 12 months after surgery. The reduce of foveolar thickness was more noticeable in groups 2 and 3 during all the period. In the postoperative period, a statistically significant improvement in central light sensitivity was revealed in patients of the 2nd and 3rd groups in comparison to similar parameters of patients of the 1st group at 3 months after surgical treatment. The same trend took place at 6 and 12 months after surgery. Conclusion. Our results showed that surgical treatment of ERM without ILM peeling yielded a better functional result compared to a group where peeling was performed within up to 12 months of follow-up. In order to reduce the risks of ERM relapse, we have developed an innovative technique of "debilitating notches", which allows us to achieve higher functional results than traditional ILM peeling and reduces the risks of relapse.

Microperimetric evaluation for different methods of epiretinal membrane surgery

PurposeTo investigate the anatomic and functional outcomes using microperimetry for the surgical methods for idiopathic epiretinal membranes (ERM).MethodsThis retrospective study included 41 eyes from 41 patients. All patients underwent combined epiretinal membrane and cataract surgery. Best-corrected visual acuity (BCVA), optical coherence tomography, and microperimetry were performed before and 6 months and 1 year after surgery. The patients were divided into 3 groups; “ERM removal only without indocyanine green (ICG) staining”, “ERM and internal limiting membrane (ILM) removal without ICG staining”, and “ERM and ILM removal with ICG staining”.ResultsPreoperatively, the ages, BCVAs, central macular thickness (CMT), and mean retinal sensitivities of central 6° (MRSs) of the groups were not significantly different (p > 0.05). Postoperatively, the MRSs of the “ERM removal only without ICG staining” and “ERM and ILM removal without ICG staining” groups were not significantly different (p > 0.05). The MRSs of the “ERM and ILM removal without ICG staining” and “ERM and ILM removal with ICG staining” groups were not significantly different (p > 0.05). However, the MRSs of the “ERM and ILM removal with ICG staining” group significantly reduced than “ERM removal only without ICG staining” group (p < 0.05).ConclusionThis retrospective study found reduced retinal sensitivity in ERM and ILM removal with ICG staining group compared to ERM removal only without ICG staining. Further studies with larger sample sizes are required.

Posterior Scleral Indentation in long axial length eyes (axial length more than 34 mm) to assist in pars plana vitrectomy and internal limiting membrane peeling in full thickness macular holes.

To assess a novel surgical technique to perform macular surgery in high myopia eyes, with axial lengths more than 34 mm, where standard sized intravitreal surgical instruments cannot reach the retinal surface during pars plana vitrectomy for internal limiting membrane (ILM) peeling in myopic macular holes. Five eyes with axial length more than 34 mm were included in this study. A 7-mm Helvoston retractor was placed under tenon's capsule and guided along the eyeball until an elevation was noticed on the macular area. This elevation shortened the operating distance, temporarily, between the sclerotomy and retinal surface, enabling the use of standard size intraocular instruments. Preoperative vision and optical coherence tomography were compared with postoperative data and used as markers of anatomical and functional success. Vision improvement and anatomical closure of the macular hole with reattachment of the retina was achieved in all five eyes. No surgical complications associated with this surgical technique were noticed. Indenting the macular area from behind the eye globe with a 7-mm Helvoston retractor in a high myopic eye with axial length more than 34 mm during pars plana vitrectomy is safe and makes surgical procedures, such as ILM removal, easier.

Commentary: Retinal changes after internal limiting membrane peeling.

The internal limiting membrane (ILM) is the innermost of the 10 retinal layers. It is a transparent membrane measuring nearly 10 microns and is formed by the basement membrane of the Müller cells. It is peeled as a standard treatment of full-thickness macular hole (FTMH). However, many reports have shown that peeling the ILM may actually damage the retina. Wollensak et al.[1] showed that ILM removal reduces the mean strength of the central retina by almost half. Histological studies performed on human and primate eyes have shown that ILM peeling causes damage to the processes and end feet of the Müller cells. A selective delay has been noted in the B-wave recovery of focal macular electroretinogram in eyes that have undergone ILM peeling. Several anatomical changes have been described after ILM peeling.[2] Swelling of the arcuate nerve fiber layer (SANFL): It was first described by Clark et al.[3] as an early postoperative change. It is seen as hypoautofluorescent arcuate striae in the macular region on fundus autofluorescence (FAF) and infrared (IR) imaging; however, it cannot be detected on either biomicroscopic fundus examination or color photograph. It is seen as a hyperreflectant swelling on spectral domain optical coherence tomography (SD-OCT). It usually disappears gradually over a period of 2–3 months. It does not seem to affect the best-corrected visual acuity (BCVA) or retinal sensitivity. Dissociated optic nerve fiber layer (DONFL): It was first described by Tadayoni et al.[4] in 2001. It is also known as “concentric macular dark spots (CMDS)” or “inner retinal dimpling”.[2] It gives the macula a ‘‘moth-eaten’’ appearance due to the presence of small depressions on the retinal contour situated along the course of retinal nerve fibers on the en face scan. SD-OCT scans show that the depth of these dimples is limited to the RNFL only. Liu et al. found three distribution patterns, namely, papillomacular bundle-dominated, scattered, and temporal raphe-spared patters.[5] Ye et al.[6] showed that DONFL appeared within two months of surgery. The number progressed during the next four months and then slowed down. The number did not change after 12 months since the surgery. It has not been found to have association with either BCVA or retinal sensitivity. Steel et al.[7] showed that the use of a diamond-dusted membrane scraper to initiate the peel is a risk factor for the formation of DONFL. The extent of DONFL has been seen to be positively associated with the amount of cellular debris on the retinal side of the peeled ILM.[8] The perioperative optical coherence tomography (OCT) for ophthalmic surgery (PIONEER) study showed that the immediate increase in the inner retinal layer thickness on intraoperative OCT following ILM peeling was associated with the development of DONFL, while the technique used for peeling did not.[9] Foveal displacement: Several authors have reported a nasal shift of the fovea, that is, shortening of the foveopapillary distance (FPD). Ishida et al.[10] reported that the displacement was greater in the temporal retina compared to the nasal retina. They further reported that the degree of the retinal displacement significantly correlated with the maximum base diameter of the FTMH. However, Nair et al.[11] reported that a temporal foveal shift may be seen in around 25% of the eyes, especially those with a longer temporal segment. Ohta et al. reported that the steepness of the foveal slope increased after ILM peeling in an asymmetrical pattern as the nasal side became significantly steeper than the temporal one.[12] None of these findings seem to affect the BCVA or retinal sensitivity. Retinal thinning: Several studies have shown that the macular volume, especially that of the temporal macula, shows a progressive reduction.[2] It has been proposed that hemi-temporal ILM peeling is as effective as conventional 360-degree peeling for the treatment of FTMH. Additionally, it is associated with less retinal displacement, lesser DONFL formation, lower rates of subjective metamorphopsia, faster visual rehabilitation, and greater safety.[13–15] We congratulate the authors for their study showing that the outcomes of papillomacular bundle sparing ILM peeling is comparable to conventional ILM peeling in terms of hole closure rates and visual gain, with the advantage of less retinal damage for the treatment of idiopathic FTMH ≤400 microns.[16] Studies with larger sample size and larger macular hole size will help validate the surgical technique.

Effect of ILM Peeling on Anatomical and Visual Outcomes in Diabetic Tractional Retinal Detachment.

The objcetive is to compare the anatomic and functional outcomes of vitrectomy between internal limiting membrane (ILM) peeling and non-ILM peeling in diabetic tractional retinal detachment (TRD). Twenty-three eyes with diabetic TRD with ILM peeling were compared with twenty-four eyes with non-ILM peeling. Best-corrected visual acuity (BCVA) was recorded at baseline and 3, 6, 9, 12 months, and end of follow-up. The mean retinal thickness across nine different regions that defined in the Early Treatment Diabetic Retinopathy Study (ETDRS) were obtained. The ETDRS grid was used to determine the extent of macular involvement. In the 1st month postoperatively, the mean BCVA of eyes with ILM peeling (1.08±0.63 LogMAR) was significantly better than eyes with ILM non-peeling (1.69±0.75 LogMAR, p=0.003). There was also a significant difference at 9 and 12 months between groups in BCVA, in favor of ILM peeling (p=0.012 and p=0.047, respectively). Seven patients (29.2%) developed epiretinal membrane (ERM), and one patient (4.1%) had ERM with the lamellar macular hole in the ILM non-peeling group, while only one patient developed ERM in ILM peeling group during the follow-up. ILM removal may be considered in diabetic TRD surgery, as it can provide rapid visual recovery. Moreover, post-operative ERM formation was less frequent in ILM peeled eyes within 1 year after surgery.

Long-term Outcomes of Vitrectomy with Internal Limiting Membrane Removal to Treat Macular Hole Retinal Detachment

Purpose: To evaluate the long-term clinical outcomes of vitrectomy with internal limiting membrane (ILM) removal for patients with macular hole retinal detachment (MHRD).Methods: We retrospectively reviewed the medical records of patients with MHRD who underwent vitrectomy with ILM removal. The incidence of retinal re-attachment and MH closure at 1 month were calculated. Factors associated with RD recurrence were investigated. Visual acuity before surgery was compared to that at the final visit.Results: Forty-two eyes were included; the mean follow-up period was 38.5 ± 19.1 months. Twenty-three eyes received gas injections and 19 silicone oil injections. Retinal re-attachment occurred in 41 (97.6%). Type 1 closure was noted in 21 eyes (51.2%) and type 2 in 20 (48.8%). Recurrent RD was noted in five eyes (14.6%) within 3 months of initial surgery. Type 2 closure was a risk factor for recurrence (p = 0.021). The logarithm of the minimum angle of resolution best-corrected visual acuity improved significantly from 1.79 ± 0.79 before surgery to 1.30 ± 0.75 after surgery (p &lt; 0.001).Conclusions: Retinal re-attachment was noted in most patients and the MH closed in approximately half of all patients after vitrectomy with ILM removal to treat MHRD. RD did not recur later than 3 months after initial surgery. Further efforts to increase the rate of type 1 closure are required.

Diamond Dust Particles Seen on Intraoperative Oct

A 68-year-old female with a full-thickness macular hole in the right eye was referred for surgical repair. The patient underwent pars plana vitrectomy with internal limiting membrane (ILM) peeling and intraocular gas injection. During the surgery, the ILM was stained using Brilliant Blue G solution, elevated using a diamond-dusted membrane scraper, and removed using vitreoretinal forceps. After ILM removal, white refractile particles (arrow) likely corresponding to diamond dust particles were noted on the retinal surface (panel A), and appeared hyperreflective on intraoperative optical coherence tomography (iOCT; panel B). Attempts at aspirating these particles were unsuccessful.

FOVEAL DISPLACEMENT IN EYES WITH EPIRETINAL MEMBRANE AFTER VITRECTOMY AND MEMBRANE PEELING.

To investigate the foveal movement in eyes with epiretinal membrane after vitrectomy and membrane peeling. A retrospective review of 85 eyes with epiretinal membrane treated with vitrectomy, membrane peeling, and internal limiting membrane removal. Using a self-designed computer program to compare the preoperative and postoperative images of optical coherence tomography to measure the amount of foveal movement. Analyze the relationships between foveal displacement, preoperative and postoperative best-corrected visual acuity, central foveal thickness, and the stage of epiretinal membrane. Most of the fovea were nasally shifted. More movement happened in the first month and almost finished in the first year. The greater degree of foveal displacement was correlated with poorer initial visual acuity and thicker central foveal thickness. In considering with the ectopic inner foveal layer staging of epiretinal membrane by structural optical coherence tomography, the foveal realignment is greatest in Stage 4 (394.47 ± 171.44 µm), followed by Stage 1 (251.21 ± 135.40 µm), Stage 2 (235.70 ± 147.51 µm), and Stage 3 (219.86 ± 117.91 µm) at the postoperative 1 month. Most eyes of epiretinal membrane had the foveal moved nasally after membrane peeling and internal limiting membrane peeling. The larger amount of foveal movement was correlated with poorer initial best-corrected visual acuity. Dystopia fovea may be another factor affecting visual acuity in addition to other biomarkers in optical coherence tomography.

MACULAR SENSITIVITY IN THE AREA OF INTERNAL LIMITING MEMBRANE PEELING IN EYES AFTER PARS PLANA VITRECTOMY WITH THE TEMPORAL INVERTED INTERNAL LIMITING MEMBRANE FLAP TECHNIQUE FOR A FULL-THICKNESS MACULAR HOLE.

To examine the relationship between retinal sensitivity and the area of internal limiting membrane (ILM) peeling during pars plana vitrectomy for a full-thickness macular hole. Twenty-four eyes a minimum of 6 months after temporal inverted flap pars plana vitrectomy for a full-thickness macular hole were included in the study. En face spectral-domain optical coherence tomography images were used to assess margins of the peeled ILM area. Microperimetry was performed to examine retinal sensitivity within the central 10°. Areas of peeled ILM in en face optical coherence tomography images were correlated with the average sensitivity threshold. Retinal sensitivities at the location of each measurement point were compared with structural abnormalities observed in en face spectral-domain optical coherence tomography images. The mean retinal sensitivity in the area of ILM removal was significantly lower compared with the area of preserved ILM (24.29 ± 3.96 dB vs. 26.19 ± 2.10 dB, P < 0.0001, respectively). The peeled ILM area showed a negative correlation with the average sensitivity threshold (r = -0.56, P < 0.01). A larger area of ILM peeling during temporal inverted flap pars plana vitrectomy for a full-thickness macular hole is related to lower retinal sensitivity in the central macula.

Устранение витреомакулярного тракционного синдрома на глазах, ранее оперированных по поводу отслойки сетчатки

Aims. Evaluate the efficiency of ILM peeling in the treatment of VMTS on eyes previously treated for retinal detachment. Materials and methods. 4 participants diagnosed with VMTS were enrolled in this study. There were 2 male and 2 female patients aged 30-64 y.o. who were previously surgically treated for their retinal detachment. 3 patients had rhegmatogenous and 1 patient had traumatic tractional retinal detachment with the mean duration of 5.75 years. 3 eyes undergone scleral buckling following subretinal fluid drainage, 1 eye underwent cataract phacoemulsification with an implantation of IOL + closed vitrectomy + pneumatic retinopexy + endolaser retinal photocoagulation + silicone oil, insertion following silicone oil removal from the vitreous cavity. All patients had some degree of myopia as well as peripheral retinal degenerations. 2 patients were diagnosed with epiretinal fibrosis and 2 other with stage 2 small full-thickness macular hole. Mean BCVA before surgery was 0.078, mean central retinal thickness was 390,25 um, small full-thickness macular hole diameter was about 320 um. Before the surgery, all patients undergone cycloscopy, where there were no indications for the additional laser photocoagulation. 3 patients underwent posterior vitrectomy 25G and 1 patient had 25G ports placed on his eye with the peeling of ILM and usage of pneumatic retinopexy, 2 eyes underwent cataract phacoemulsification with IOL implantation. Results and discussion. All surgical interventions were done without any complications. Since there were conjunctival scars left after the previous surgeries, conjunctiva did not show any displacement during the sclerotomy procedures, which led to the formation of post-sclerotomy holes. This fact forced us to make knot sutures, which resulted in foreign body sensations in our patients during the post-op period. Intraoperatively, all patients had their ILM removed, which was proved by OCT in the post-op period. Mean BCVA after operations was 0.3. Mean Central retinal thickness was 314 um based on OCT data in the post-op period. Patients were recommended to undergo cycloscopy 1 month after the surgery and then twice every year. There were no retinal detachment relapse observed in the post-op period. Conclusion: 1. Removal of ILM in patients, that were previously operated due to retinal detachment, is considered as an effective method in the treatment of VMTS. It is clinically manifested as visual acuity improvement, retinal thickness reduction, lamellar hole closure and the absence of full thickness macular hole formation risk in the early and late post-op periods. No retinal detachment relapses were observed. 2. Presence of conjunctival scars following previous retinal detachment surgical interventions leads to the hole formation following sclerotomy procedures, which causes foreign body sensations in patients during the post-op period. 3. Endovitreal surgical intervention for the retinal detachment should include ILM peeling to prevent formation of VMTS in the post-op period. Key words: vitreomacular traction syndrome (VMTS), Internal limiting membrane (ILM), rhegmatogenous retinal detachment ( RRD), optic coherence tomography (OCT).

Підвищення клінічної ефективності хірургічного лікування регматогенного відшарування сітківки шляхом оцінювання імунологічних та анатомо-морфологічних показників: огляд літератури

Introduction. Closed subtotal vitrectomy (CSV) is used to treat rhegmatogenous retinal detachment (RRD), but even with successful surgery performed at a relatively early stage, some patients still have low visual acuity and persistent color perception defects. Therefore, the combination of CVS with the internal limiting membrane (ILM) peeling in RRD can improve clinical outcomes in the postoperative period. The aim. To determine the role of ILM peeling and its influence on the functional and morphological state of the macula after RRD surgery in order to maximize the results of visual acuity after retinal detachment and clarify the indications for ILM removal in RRD. Materials and methods. Analysis of the literature shows that in many cases, despite the full ft of the detached retina, visual acuity is not restored in full. There are almost no data comparing the effect on visual acuity of ILM removal during vitrectomy in the remote period, hemodynamic disorders in the macular area according to optical coherence tomography (OCT) angiography in patients with RRD. Results. Despite the fact that ILM peeling in RRD significantly reduces the incidence of epiretinal fibrosis the anatomical and morphological changes of the retina after ILM peeling and their impact on postoperative clinical outcomes should be taken into account. The determination of blood biomarkers has the potential to better predict the risk of proliferative vitreoretinopathy (PVR) after surgery to inhibit the pathological reaction that causes the formation of fibrous films on the retina, which in turn significantly worsen the clinical outcomes in the postoperative period. Conclusions. Thus, a combination of appropriate surgical techniques and new diagnostic markers, both clinical and immunological, can help to improve the diagnosis and prognosis of RRD.

Результаты хирургического лечения регматогенной отслойки сетчатки с макулярным разрывом

Purpose. Analysis of functional and anatomical results surgical treatment of retinal detachment and macular hole (RDMH) with internal limiting membrane (ILM) peeling and silicone tamponade. Material and methods. Analysis of results surgical treatment of 17 patients (17 eyes) with RDMH was carried out. Disease duration ranged from 2 weeks to 3 months. Visual acuity before surgical treatment ranged from no light perception to 0.05 (on average 0.01±0.02). All patients underwent endovitreal surgery with ILM removal. Then retinal holes were localized at periphery with further endolaser coagulation or cryocoagulation and silicone oil (5700 cSt) tamponade. Results. Retinal adhesion was noted in all eyes after primary surgery. Closure of hole was successful in 16 patients. After operation, visual acuity improved in all patients, averaging 0.11±0.09. Conclusion. Vitrectomy with IPM removal and silicone oil (5700 cSt) tamponade in treatment of RDMH made it possible to achieve reattachment of retina in 17 patients, complete closure of macular hole in 16 of 17 patients. One patient, according to optical coherence tomography, showed decrease diameter of macular hole after 12 months. Positive functional effect was achieved in increase visual acuity to average of 0.15±0.15 after 12 months. Key words: retinal detachment, macular hole, vitrectomy, internal limiting membrane removal, silicone oil tamponade, visometry, optical coherence tomography.

Results of Pars Plana Vitrectomy for Different Types of Macular Holes.

PurposeTo compare different types of macular holes regarding the anatomic and functional success following pars plana vitrectomy (PPV) and internal limiting membrane (ILM) removal.MethodsA retrospective review of all patients with macular holes treated by PPV, ILM removal with gas tamponade from January 2014 to July 2017 in Magrabi Eye Hospital.ResultsOne hundred fifty-seven eyes of 153 patients were analyzed. The eyes were classified according to the etiology of macular hole into four groups: 79 eyes with idiopathic macular hole (IMH), 51 eyes with traumatic macular hole (TMH), 16 eyes with macular hole in diabetic patients (DMH) and 11 eyes with myopic macular hole (MMH). We classified the IMH group based on the International Vitreomacular Traction Study Classification according to size into 3 subgroups; subgroup 1: ≤250µ, subgroup 2: >250 to 400µ and subgroup 3: ≥400 µ. All types of macular hole showed statistically significant postoperative improvement in BCVA compared to the baseline except cases with MMH. Anatomic postoperative hole closure was achieved in 86.1%, 60.7%, 43.65%, an 45.46% of eyes with IMH, TMH, DMH and MMH, respectively. In eyes with IMH, closure rate in subgroup 1 was significantly higher than in subgroups 2, and 3.ConclusionPPV, ILM peel and C2F6 technique yielded variable anatomic and functional outcomes in different types of macular holes. Anatomic results were most favorable in IMH and least favorable in MMH. The smaller the diameter of the hole the better the results. The underlying pathogenetic mechanisms that lead to different types of macular holes are pivotal in determining the final outcome.

A Critical Analysis of Non-Complicated Macula-Off Rhegmatogenous Retinal Detachment with and Without Internal Limiting Membrane Peeling

Background: There is abundant and even confusing information in the available literature concerning the role of Internal Limiting Membrane (ILM) removal in macular conditions secondary to non-complicated macula-off Rhegmatogenous Retinal Detachment (RRD) repair. This retrospective, multicenter, long-term study aimed to analyze the incidence of Epiretinal Membrane (ERM) proliferation and other surgical complications and to compare the postoperative microstructural and multimodal imaging findings and correlate them with the final postoperative Best-Corrected Visual Acuity (BCVA) in selected eyes. Methods: This long-term retrospective study included 230 eyes divided into three groups according to the surgical management performed for uncomplicated macula-off RRD: 125 eyes in the buckle group underwent scleral buckle techniques; 55 eyes in the non-peeling group underwent primary vitrectomy with no ILM peeling; 50 eyes in the peeling group with primary preoperative or secondary postoperative presence of significant ERM proliferations underwent the ERM-ILM en-bloc complex removal or double-staining removal techniques. Results: The postoperative incidence of ERM was 23.2% (29 eyes) in the buckle group, 23.6% (13 eyes) in the non-peeling group, and 2.0% (one eye) in the peeling group (p<0.05; Student’s t-test). The mean postoperative BCVA difference among the buckle group, peeling group, and non-peeling group was significant (logarithm of the minimum angle of resolution, 0.40 ± 0.33 vs. 0.47 ± 0.16 vs. 0.28 ± 0.19, respectively). Postoperative multimodal imaging tests yielded abnormal retinal thickness in the three groups, with a diffuse optic nerve fibre layer and ellipsoid band disruptions predominantly in the peeling group, and a normal foveal profile in the buckle and non-peeling groups. Conclusion: Multiple structural alterations in spectral-domain optical coherence tomography biomarkers and a significant reduction in retinal sensitivity were observed in the peeling group. Eyes that developed secondary ERM proliferations in the buckle group and in the non-peeling group showed statistically significant upgrading in BCVA once the ERM proliferation and ILM were removed. Ultimately, our study contributes findings pertaining to severe consequences in macular structure and function. We can conclusively state that ILM removal with the main objective of avoiding macular ERM proliferation is not justified because of the high rate of potential macular complications and poor visual results.