Membrane In Macular Hole Surgery Research Articles

Morphology of Peeled Internal Limiting Membrane in Macular Hole Surgery.

Purpose The aim of this work was to describe the ultrastructure and behavior of peeled internal limiting membrane (ILM) in macular hole (MH) surgery. Methods Seven patients with MH were included, and vitrectomy with ILM peeling was performed in all patients. The ILM inverted flap technique was used. Two other flaps of ILM of the same patient were collected and studied using light and transmission electron microscopy (TEM). ILM cell type, distribution, and morphology were analyzed, and the proliferation or fusion potential of the ILM interface was evaluated. Results ILM vitreous sides in apposition showed signs of proliferative fibrotic activity, producing a basal membrane that merges ILM sides. Conclusions Epiretinal cells in ILM show proliferative capacity, with formation of microfibrils between adjacent sides of the ILM, which may explain adherence of ILM flaps to the hole border, contributing to closure of the hole in MH surgery. This trail is registered with NCT03799575.

I. Indocyanine Green Should Be Used to Facilitate Removal of the Internal Limiting Membrane in Macular Hole Surgery: Should Indocyanine Green Be Used to Faciliate Removal of the Internal Limiting Membrane in Macular Hole Surgery?

Indocyanine green (ICG) is one of several vital dyes that are used in vitreoretinal surgery to aid visualization of diaphanous collagenous tissues in what has been called chromovitrectomy. As shown herein, much has been written about the use and rather narrow safety profile of ICG. The discussion surrounding its applications would have ended long ago were it not for the occasional patient who keeps returning to the office with permanent central scotomas after ICG-assisted macular hole surgery. The purpose of this Viewpoint is to reemphasize potential methods of proper use and clarify safety issues of this particular vital dye that enhances surgical technique but not necessarily visual outcome.

II. Indocyanine Green Should Not Be Used to Facilitate Removal of the Internal Limiting Membrane in Macular Hole Surgery

II. Indocyanine Green Should Not Be Used to Facilitate Removal of the Internal Limiting Membrane in Macular Hole Surgery

DELINEATION OF THE VITREOUS AND POSTERIOR HYALOID USING BROMOPHENOL BLUE

To describe visualization of the vitreous and the posterior hyaloid membrane using bromophenol blue during vitrectomy for macular hole and retinal detachment. Six patients with macular holes and four with retinal detachments were included in the study. Before and after surgery, complete clinical examination, including funduscopy and measurements of best-corrected visual acuity and intraocular pressure, was performed. Additional functional tests, such as fluorescein angiography, optical coherence tomography (Stratus OCT; Carl Zeiss Meditec, Jena, Germany, Germany), Goldmann perimetry, and multifocal electroretinography as well as photography of the posterior pole, were performed for macular hole patients. Bromophenol blue was used in concentrations of 0.2%. During macular hole surgery, the dye was injected into the air-filled globe, while during surgery for retinal detachment, the globe was partially filled with perfluorocarbon before dye injection after induction of a posterior vitreous detachment to stain the vitreous peripherally. Bromophenol blue provided sufficient staining of the attached posterior hyaloid membrane and vitreous remnants in the periphery. This was especially helpful for patients in whom a posterior vitreous detachment could not be induced mechanically by suction using the vitrectomy probe alone, as seen in three of six interventions for a macular hole in this series. In addition, staining of the vitreous or vitreous remnants in the periphery and at the vitreous base was seen in all patients and helped to completely remove the vitreous in a controlled fashion. After macular hole surgery, increase of visual acuity from 20/100 (mean) to 20/40 was seen during follow-up up to 6 months. In one case, the hole persisted and required a second operation. Finally, closure of the hole was achieved in all patients. After retinal detachment surgery, reattachment was achieved in all cases. No dye-related adverse events were seen during follow-up as shown by the functional tests (visual acuity measurement, electroretinography, and perimetry) applied. Delineation of the vitreous and the posterior hyaloid using bromophenol blue staining greatly facilitates vitreoretinal procedures. Bromophenol blue appeared to be a very helpful and safe tool to visualize the posterior hyaloid membrane in macular hole surgery and assured its complete separation from the retinal surface. The dye also helped to remove vitreous at the vitreous base during retinal detachment surgery. Therefore, bromophenol blue appears as a very good alternative to triamcinolone, which has been used for this purpose, because the dye has no pharmacological properties and no side effects are likely to occur such as cataract formation and increase in intraocular pressure. Further studies including larger numbers of patients are mandatory.

Clinical evaluation of the use of indocyanine green for peeling the internal limiting membrane in macular hole surgery

To evaluate the role of indocyanine green (infracyanine) in macular hole surgery. A retrospective review of 38 consecutive eyes with macular hole, operated on with internal limiting membrane peeling (ILM), using or not using infracyanine (ICG), diluted in glucose 5% and filtered. Anatomical and functional results were analysed in each group, using visual field testing, fluorescein fundus angiography and particularly blue filter fundus photographs for the detection of retinal pigment epithelial changes and lesions of optic nerve fibres layer. Fifteen eyes underwent surgery without ICG and 23 eyes with ICG. The mean period of follow-up was 10 months. The duration of surgery was significantly lower in the group with ICG than without (P < 0.001). Overall, 84% of the holes closed without difference between both groups. The improvement in vision at 1, 6 and 12 months was similar in both groups. Fewer defects in the optic nerve fibres layer were observed in the group with ICG than without (P = 0.02). Staining with ICG revealed the presence of an associated epiretinal membrane in 61% of eyes, whereas it was clinically visible in only 17.5% before surgery. Using ICG for ILM peeling produced similar visual results to those obtained without ICG. It reduced significantly the duration of surgery and the trauma to the optic nerve fibres layer, without increasing the risk of retinal pigment epithelial damage. However, in the light of recent reports about the possible toxicity of ICG, its use should be restricted in clinical practice to difficult cases.

Indocyanine green-assisted peeling of the internal limiting membrane in macular hole surgery affects visual outcome: a clinicopathologic correlation

Purpose To report the ultrastructure of the internal limiting membrane (ILM) after macular hole surgery with indocyanine green (ICG) staining and to investigate an association with the postoperative functional outcome. Design Retrospective, noncomparative analysis of a consecutive case series. Methods Twenty eyes of 20 patients after macular hole surgery with ICG staining were included. Visual acuity and Goldmann perimetry were obtained before and after surgery. The ILM was obtained during three-port pars plana vitrectomy for idiopathic macular hole. Twenty-five milligrams of sterile ICG powder was dissolved in 5 ml of sterile water as recommended by the manufacturer and then diluted in balanced salt solution. The ultrastructure of the ILM was analyzed using light and transmission electron microscopy. Osmolarity and pH of the ICG solution were measured preoperatively. Results There was no statistically significant improvement of postoperative visual acuity after ICG-assisted peeling ( P = .755). In seven patients, postoperative visual field defects occurred. Indocyanine green-stained specimens revealed cellular elements resembling the plasma membrane of Müller cells and other undetermined retinal structures adherent to the retinal side of the ILM. Histologic findings disclosed no difference between patients with and without visual field defects after the use of ICG. The osmolarity of the ICG solution applied was 275 mOsm; pH was 7.5. Conclusions Intravitreal application of ICG may cause retinal damage by altering the cleavage plane to the innermost retinal layers. That may result in less improvement of visual acuity and unexpected visual field defects. The underlying mechanisms of action remain unclear and are the subject of ongoing investigations.

Retinal pigment epithelial changes after macular hole surgery with indocyanine green-assisted internal limiting membrane peeling

PURPOSE: To report the results of macular hole surgery using indocyanine green to improve visualization and facilitate peeling of the internal limiting membrane. METHODS: A retrospective noncomparative review of a consecutive series of 22 patients (22 eyes) who underwent macular hole repair using indocyanine green to facilitate visualization of the internal limiting membrane was performed. One patient was excluded because of a history of a rhegmatogenous retinal detachment. All patients underwent a three-port pars plana vitrectomy with internal limiting membrane peeling. Indocyanine green (0.1% solution) was used to assist in the visualization of the internal limiting membrane. The main outcome measures were postoperative visual acuity, macular hole status, and postoperative retinal pigment epithelial changes. RESULTS: In 21 eyes, the median preoperative best-corrected visual acuity was 20/200 (range, 20/60 to counting fingers at 5 feet). The median postoperative visual acuity was 20/400 (range, 20/60–1/200) with an average follow-up of 13 weeks. The macular hole was closed in 18 eyes (86%) at the most recent follow-up. Ten eyes were found to have atrophic retinal pigment epithelium changes in the area of the previous macular hole. CONCLUSIONS: Indocyanine green assists in visualization of the internal limiting membrane in macular hole surgery. In our series, 10 eyes had unusual atrophic changes in the retinal pigment epithelium at the site of the previous macular hole, or in the area where the indocyanine green solution would have had direct access to the bare retinal pigment epithelium cells. Although the use of indocyanine green improves visualization and assists with peeling of the internal limiting membrane, the safety and potential toxicity of indocyanine green to the retinal pigment epithelium require further investigation.

Macular changes after peeling of the internal limiting membrane in macular hole surgery

PURPOSE: To report the incidence of macular changes following pars plana vitrectomy with peeling of the internal limiting membrane (ILM) for idiopathic macular hole. DESIGN: Prospective consecutive series. METHODS: In a prospective study 105 eyes of 105 patients underwent vitrectomy for idiopathic macular holes. Surgery consisted of a standard three-port vitrectomy, induction of a posterior hyaloid detachment, removal of epiretinal membranes including the ILM, fluid-air exchange and intraocular gas tamponade (15% hexafluoroethane (C2F6) gas mixture) followed by head-down positioning for at least five days. No adjuvants were used during surgery. In addition to the clinical examination, static microperimetry using a Rodenstock scanning laser ophthalmoscope (SLO-105) was performed pre- and 6 or 12 weeks postoperatively. The stimulus size was 0.2 degrees (Goldmann II), intensities employed were 0 and 12 dB. For all tests, 20-degree fields were used. RESULTS: Anatomic closure of macular holes was achieved in 92 (87.6%) of 105 patients by one operation. Eight patients underwent a successful second procedure. The closure rate after two operations was 95.2%. Best corrected visual acuity increased from a median of 0.2 (range 0.05 to 0.5) preoperatively to a median of 0.5 (range 0.05 to 1.0) postoperatively. Anatomical macular changes were found in 8 (7.6%) patients: There were two cases of macular edema following secondary cataract extraction and six cases of retinal pigment epithelium changes. Formation of postoperative epiretinal membranes or late reopenings were not noted. Small, mostly asymptomatic paracentral scotomata were seen in 59 (56.2%) of 105 patients. CONCLUSION: Anatomical changes of the macula following vitrectomy with removal of the ILM are infrequent. However, paracentral scotomata observed in our series might be caused by a trauma to the nerve fibers during ILM peeling. To achieve reliable results a standardized procedure for microperimetry should be developed.

Indocyanine green staining and removal of internal limiting membrane in macular hole surgery: histology and outcome

PURPOSE: To report the surgical technique, outcome, and histologic findings involving indocyanine green staining and removal of internal limiting membrane in primary macular hole surgery. METHODS: Prospectively, consecutive patients with idiopathic macular hole or myopic macular hole with retinal detachment were recruited. After pars plana vitrectomy and epiretinal membrane removal, the internal limiting membrane was stained and removed. The specimens were stained using hematoxylin and eosin and periodic acid-Schiff. Immunohistochemical staining was also performed for glial fibrillary acidic protein, vimentin, type I and type IV collagen, and actin. RESULTS: Among 10 patients (10 eyes) in the study, nine eyes had stage 3 or 4 macular hole. Four of them had chronic macular hole. The tenth patient had retinal detachment resulting from a myopic macular hole. Postoperatively, all cases had closure of macular hole without an elevated edge and the retina was attached. Seven patients had improvement of 2 or more Snellen lines, whereas visual acuity remained the same for the other three patients. In six eyes in which complete histologic examinations were feasible, internal limiting membrane was confirmed and two eyes also had a small amount of epiretinal membrane. Myofibrocytes in internal limiting membrane, either scattered or as a single layer, were found in three cases. CONCLUSIONS: Removal of indocyanine green-stained internal limiting membrane around idiopathic macular hole or myopic macular hole with retinal detachment is confirmed with histology and may contribute to macular hole closure and retinal reattachment.

Staining of internal limiting membrane in macular hole surgery.

Removal of internal limiting membranes (ILMs) is a potentially useful surgical approach to close an idiopathic macular hole. However, the removal of ILMs is difficult to perform because of poor visibility of the ILMs. We have developed a technique for staining the ILM with a solution of indocyanine green to facilitate the removal of ILMs in eyes with an idiopathic macular hole. Thirteen eyes of 13 patients (8 women and 5 men, aged from 54 to 68 years) with idiopathical macular hole stage 3 or stage 4 that underwent removal of ILMs using this technique had an anatomical closure rate of 92% and an improvement of visual acuity of 89% (>/=2 Snellen letter chart lines). The excised specimens were evaluated using transmission electron microscopy. Our results show that this technique is safe and useful in visualizing the ILM, leading to the performance of successful removal of an ILM with least damage to the retina. Arch Ophthalmol. 2000;118:1116-1118