Residual Internal Limiting Membrane Research Articles

Foveal-Sparing ILM Peeling with ILM Flap Transposition over the Macular Hole for Repair of Full-Thickness Macular Holes.

Full-thickness macular holes, defined as full-thickness defects of the fovea, lead to central scotoma and deterioration of vision. Apart from peeling of the internal limiting membrane (ILM), ILM flap techniques have been reported to have potential in improving results in macular hole surgery. In addition, foveal-sparing ILM peeling gives a high macular hole closure rate and improvement in postoperative visual acuity. The aim of this study was to examine outcomes in a cohort of patients with full-thickness macular holes that underwent vitrectomy with foveal-sparing ILM peeling and transposition of an ILM flap over the macular hole. This retrospective study included patients scheduled for pars plana vitrectomy with foveal-sparing ILM peeling, combined with ILM flap transposition over the macular hole, for macular hole repair. All patients received a gas tamponade with 20% sulphur hexafluoride and were encouraged to undergo postoperative face-down positioning for 48 hours after surgery. Optical coherence tomography (OCT) imaging of the macula and distance-corrected visual acuity (DCVA) were performed before and 3 months after surgery. In total, 42 eyes of 42 patients were included in this study. Leaving a broad area of residual ILM at the foveal rim led to a high risk of failure in macular hole closure, while leaving a narrow zone of residual ILM at the foveal rim resulted in high macular hole closure rates (97% type 1 closure and 3% type 2 closure), with a median improvement of DCVA of 4lines [interquartile range (IQR): 3 to 6] among pseudophakic and 3.5 lines (IQR: 2 to 5) among phakic patients. A combination of foveal-sparing ILM peeling with ILM flap techniques was shown to be a safe and effective surgical option for patients with full-thickness macular holes, resulting in a high macular hole closure rate and improvement in visual acuity in the majority of patients.

Inverted Pedicled Internal Limiting Membrane Flap Attached to an Optic Disc with Autologous Blood Clot for Large Macular Holes.

An inverted ILM flap might be accidentally separated from the retina or sucked away during surgery for large macular holes (MHs). This article is to determine the efficacy of a new inverted pedicled internal limiting membrane (ILM) flap attached to an optic disc with an autologous blood clot (ABC) technique for the treatment of large MHs. An inverted pedicled ILM flap connected to the optic disc with ABC was used to treat 12 consecutive patients with significant macular holes (>600 m). The ILM was first peeled off around MH as a semidiameter of about 1.5 diameters of the optic disc. The superior residual ILM was used to produce a pedicled ILM flap that was connected to the optic disc and was later inverted to cover the MH. The macular hole was covered with a repositioned flap larger than 2 MH diameters in an inverted way. ABC was used to fasten the flap, followed by fluid-air exchange with air or C3F8 as tamponade. Spectral domain-optical coherence tomography (SD-OCT) and best-corrected visual acuity (BCVA) were performed at each postoperative follow-up. The mean aperture and base macular hole diameters were 737.9 ± 109.6 µm (range, 607-982 µm) and 1244.3 ± 227.4 µm (range, 975-1658 µm). All macular holes (100%) were closed after a single surgery without intraoperative or postoperative complications related to the ILM transposition technique. At the last postoperative visit, we found one eye with a U-shaped closure, three eyes with W-shaped closures, and eight eyes with V-shaped closures. No postoperative flap closures were noted in all cases. The preoperative mean BCVA was 1.5 ± 0.3 (range, 1.1-2.0). After a mean follow-up of 5.3 ± 4.8 (range, 3-16) months, the postoperative mean BCVA was 0.8 ± 0.2 (range, 0.6-1.1), and the difference was statistically significant (p < 0.05). This novel technique is safe and suitable for large MHs and can be an alternative option for accidental ILM flap loss during other inverted ILM flap operations.

Fovea sparing internal limiting membrane peeling for idiopathic macular holes-Report of unfavourable outcomes of a surgical technique.

To describe the outcomes of fovea-sparing internal limiting membrane peeling for idiopathic macular holes. This was a prospective, interventional case series in patients with idiopathic macular holes. Patients underwent fovea-sparing internal limiting membrane (ILM) peeling with the help of a finesse loop. The primary outcome measure was successful anatomical closure. Secondary outcome measures were postoperative improvement in best corrected visual acuity (BCVA) or any surgical complications. The study included 22 eyes of 22 patients (median age of 61 (IQR 58 to 66) years). The median basal diameter of the holes was 1054 (IQR 961.5 to 1278) microns, while the median minimal linear diameter was 697 (IQR 461.5 to 786) microns. Successful anatomic closure was achieved in nine cases out of 22 (40.9%). BCVA improved from 20/125 preoperatively to 20/80 at the end of the follow-up. There was no difference in baseline parameters between eyes with closure, versus eyes with an open hole. One eye had an iatrogenic break in an attempt to reinitiate peeling and create a fovea-sparing flap. One of the eyes had an ERM formation at end of 3 months. Our outcomes of fovea-sparing ILM peeling in idiopathic macular holes were unfavourable. The residual ILM could be causing tangential traction resulting in non-closure.

En Face Image-Based Analysis of Epiretinal Membrane Formation after Surgery for Idiopathic Epiretinal Membrane

To analyze en face epiretinal membrane (ERM) images constructed using swept-source (SS) OCT and to determine the incidence of ERM formation after ERM surgery and its effects on visual function. Retrospective, consecutive observational study. Consecutive series of 73 eyes (71 patients) with idiopathic ERM that underwent vitrectomy with both ERM and internal limiting membrane (ILM) peeling. We retrospectively reviewed the data of the 73 eyes included in the study. During surgery, the ERM was removed as extensively as possible, and the ILM was removed such that the area of ILM peeling was at least larger than the parafoveal area. All patients underwent comprehensive ophthalmologic examinations, including assessments of best-corrected visual acuity and metamorphopsia, before and at 2 weeks and 6 months after the surgery. En face images constructed using SS OCT were used to investigate ERM formation. The incidence of ERM formation at 6 months after the surgery, effects of ERM formation on visual function, and the relationship between ERM formation and the extent of ERM and ILM peeling. At 6 months after ERM and ILM peeling, 8 eyes (11.0%) showed ERM formation (formation group). Twenty eyes (27.4%) exhibited remnant ERM without ERM formation (remnant group), whereas 45 eyes (61.6%) showed no ERM (no ERM group). In both the remnant and no ERM groups, best-corrected visual acuity and metamorphopsia showed significant improvements after ERM surgery (both P < 0.01); these improvements were not seen in the formation group (P= 0.067 and P= 0.053, respectively). However, no significant differences were found in preoperative and postoperative best-corrected visual acuities and metamorphopsia among the 3 groups. In the formation group, ERM formation occurred only in the area with residual ILM. Most patients who underwent ILM peeling in which the area of the peeling covered the ERM belonged to the no ERM group (97.7%; P < 0.01). Epiretinal membrane formation does not affect visual function significantly when the area of ILM peeling is larger than the parafoveal area. When the ILM peeling area covers the ERM area, postoperative ERM formation can be prevented.

Intraoperative OCT Findings May Predict Postoperative Visual Outcome in Eyes with Idiopathic Macular Hole

To determine the significance of correlation between the intraoperative OCT findings and postoperative retinal morphologic and physiologic features in eyes with an idiopathic macular hole (MH). Retrospective, interventional case-control study. Pars plana vitrectomy with internal limiting membrane (ILM) peeling and air tamponade was performed on 33 eyes with idiopathic MHs. All of the eyes were followed up for at least 6 months. The intraoperative OCT (Rescan; Carl Zeiss Meditec, Oberkochen, Germany) images were used to detect the presence of residual fragments at the edge of the MH, and the eyes were divided into those with residual fragments (the residual group) and those without residual fragments (the nonresidual group). The preoperative and postoperative OCT (Spectralis; Heidelberg Engineering, Heidelberg, Germany) findings and visual acuities were compared. The area of the hyperreflective tissue at the inner layer of the closed MH was measured with ImageJ software (National Institutes of Health, Bethesda, MD). Residual fragments were detected in 22 eyes (67%), including 3 eyes with residual ILM fragments, and were not detected in 11 eyes. Age, gender, preoperative vision, refractive errors, and axial length were not significantly different between the 2 groups. The presence of residual fragments was associated significantly with the presence of epiretinal membrane (P= 0.040) and with epiretinal membrane, epiretinal proliferation, or both (P= 0.007) in the preoperative OCT images. However, they were not associated significantly with the presence of epiretinal proliferation and ILM fragments. The MHs were closed after surgery in all eyes with type 1 closure. Postoperative vision was significantly worse in the residual group at 3 and 6 months (P= 0.029 and P= 0.037, respectively). The sizes of the hyperreflective inner retinal tissue were significantly larger in the residual group than those in the nonresidual group at 1 and 3 months after surgery (P < 0.01). The sizes of the tissue decreased significantly after surgery in the residual group (P < 0.001) but not in the nonresidual group. The residual fragments detected at the edge of the MH by intraoperative OCT may be the hyperreflective tissue observed in closed MHs and are predictors of limited postoperative visual improvements.

Postoperative eccentric macular holes after vitrectomy and internal limiting membrane peeling.

The purpose of this study was to describe the incidence, clinical characteristics, and outcome of eccentric macular holes presenting after vitrectomy and internal limiting membrane (ILM) peeling for the treatment of macular pathology and discuss the pathogenesis of holes formation. A retrospective, noncomparative, interventional case-series study of five patients who developed eccentric macular holes postoperatively following vitrectomy in 198 consecutive patients who underwent ILM peeling for idiopathic macular hole and epiretinal membrane formation between 2008 and 2015. Five patients (2.5%) developed full-thickness eccentric macular holes postoperatively. Three patients presented with a single eccentric macular hole, one patient had an eccentric hole after a failed idiopathic macular hole surgery and one patient developed four eccentric macular holes. The mean diameter of the holes was 584μm (range 206-1317μm) and the average time of holes formation after vitrectomy was 27.7weeks (range 1-140weeks). Postoperative best-corrected visual acuity ranged from "counting fingers" to 20/25. The eyes with the holes distant from the fovea had the best final visual acuity. No further intervention was attempted and no complications occurred. The mean follow-up time was 26.8months. The postoperative macular holes after vitrectomy and ILM peeling were variable in number, size, and time of appearance but remained stable and were not associated with any complications. The pathogenesis of macular holes is most consistent with contraction of the residual ILM or secondary epimacular proliferation probably stimulated by ILM peeling.

Evaluation of the dual staining technique for complete removal of idiopathic epimacular membranes

Purpose This study tries to evaluate the usefulness of the dual staining first with Triamcinolone acetonide (TA) to effectively visualize and remove the fibrous component of idiopathic epimacular membrane (EMM) and then with brilliant blue G (BBG) to selectively remove the internal limiting membrane (ILM). The primary outcome was the visual acuity improvement and the concomitant decrease in the central macular thickness (CMT) after surgery, and the secondary outcome was the condition of the ILM after this dual staining. Subjects and Methods A prospective, non-randomized, observational cohort study including 15 eyes .The inclusion criterion was a clinically detectable idiopathic EMM diagnosed by fundus examination or optical coherence tomography (OCT), causing a decrease of visual acuity. The exclusion criteria included prior intravitreal injection of TA or antivascular endothelial growth factor, ocular inflammation or prior trauma. During a standard 23 G vitrectomy, peeling the EMM was carried out after administration of TA, BBG (0.25 mg /mL) was injected onto the retinal surface utilizing the ''dry method'' or the ''air-filled technique''. Both stains will be completely washed out immediately. Then the surgeon recorded the characteristics of the underlying ILM before peeling. Postoperatively the patients were followed up at 1 day, 1 week, 1 month and at 6 months. Primary and secondary outcomes were recorded. Results Our patients included 8 (53.3%) females and 7 males (46.7%). A single surgeon performed all surgeries. TA was used to identify the posterior hyaloid in all 14 cases (93.3%) with no prior vitreous surgery and to effectively visualize and remove the idiopathic EMM in all 15 cases. Three (20%) of the cases had EMM remnants after BBG staining. When this dye was used to stain the ILM during surgery, the unstained EMM clearly stood out against the ILM, which was stained blue. After EMM peeling, all of the eyes had residual ILM except one (6.3%). In all eyes, the surgeon was unable to determine the status of the ILM before BBG staining. The ILM was present and damaged in 8 eyes (53.3%), while it was present and undamaged in 6 (40%). The mean preoperative CMT in eyes were the ILM was found to be damaged on table was 565.3 ± 79.9 μm, while the mean preoperative CMT in eyes were the ILM was undamaged was 446.6 ± 34.4 microns, this was statistically significant (P = 0.005). At 6 months, decimal BCVA improved from 0.18 ± 0.06 at baseline to 0.53 ± 0.11 (P = 0.005). Again at 6 months, the CMT also improved from 506.2 ± 90.03 ΅m at baseline to 365.8 ± 53.3 μm (P Conclusions In conclusion, dual staining starting with TA effectively led to adequate visualization and removal of the posterior hyaloid as well as the fibrous component of the idiopathic EMM. The subsequent BBG administration in an air filled vitreous (the dry technique) helped selective removal of the ILM with no deleterious effects on the functional or the anatomical outcomes of the procedure as demonstrated by the significant improvement in both the BCVA and the CMT 6 months after surgery.

PHOTORECEPTOR CHANGE AND VISUAL OUTCOME AFTER IDIOPATHIC EPIRETINAL MEMBRANE REMOVAL WITH OR WITHOUT ADDITIONAL INTERNAL LIMITING MEMBRANE PEELING

To compare the postoperative photoreceptor status and visual outcome after epiretinal membrane removal with or without additional internal limiting membrane (ILM) peeling. Medical records of 40 eyes from 37 patients undergoing epiretinal membrane removal with residual ILM peeling (additional ILM peeling group) and 69 eyes from 65 patients undergoing epiretinal membrane removal without additional ILM peeling (no additional peeling group) were reviewed. The length of defects in cone outer segment tips, inner segment/outer segment junction, and external limiting membrane line were measured using spectral domain optical coherence tomography images of the fovea before and at 1, 3, 6, and 12 months after the surgery. Cone outer segment tips and inner segment/outer segment junction line defects were most severe at postoperative 1 month and gradually restored at 12 months postoperatively. The cone outer segment tips line defect in the additional ILM peeling group was significantly greater than that in the no additional peeling group at postoperative 1 month (P = 0.006), and best-corrected visual acuity was significantly worse in the former group at the same month (P = 0.001). There was no significant difference in the defect size and best-corrected visual acuity at subsequent visits and recurrence rates between the two groups. Patients who received epiretinal membrane surgery without additional ILM peeling showed better visual and anatomical outcome than those with additional ILM peeling at postoperative 1 month. However, surgical outcomes were comparable between the two groups, thereafter. In terms of visual outcome and photoreceptor integrity, additional ILM peeling may not be an essential procedure.

RESIDUAL INTERNAL LIMITING MEMBRANE AFTER EPIRETINAL MEMBRANE PEELING

To determine the degree of residual internal limiting membrane (ILM) after idiopathic epiretinal membrane (ERM) peeling and the usefulness of staining with brilliant blue G. A prospective, multicenter, observational study of 98 eyes undergoing pars plana vitrectomy and membrane peeling for idiopathic ERM. All eyes underwent core vitrectomy (20, 23, or 25 gauge) followed by intravitreal triamcinolone to verify that the posterior hyaloid had been removed. Brilliant blue G (0.2 mL of 0.25 mg/mL) was injected into the vitreous cavity and washed out immediately. The ERM was peeled and then the surgeon observed and recorded the characteristics of the underlying ILM. The posterior pole was restained with brilliant blue G (0.2 mL of 0.25 mg/mL), and the same observations on the characteristics of the ILM were recorded. Peeling of the remaining ILM was performed. The main outcome measured was the status of the ILM after ERM peel. Secondary outcomes included best-corrected visual acuity and central macular thickness at 6 months postoperatively. After ERM peel, all of the eyes had residual ILM. In 74 eyes, the ILM was present and damaged, whereas in 24 eyes, the ILM was present and undamaged. In 37 eyes, the operating surgeon was unable to determine the status of the ILM before brilliant blue G staining. At 6 months, the logarithm of the minimum angle of resolution best-corrected visual acuity improved from 0.75 ± 0.39 at baseline to 0.31 ± 0.26 (P < 0.0001). The central macular thickness also improved from 460 ± 91 μm at baseline to 297 ± 102 μm (P < 0.003). Internal limiting membrane is frequently still present after ERM peeling. Staining with brilliant blue G facilitates its identification.

Fovea-Sparing Internal Limiting Membrane Peeling for Myopic Traction Maculopathy

To investigate the effectiveness and safety of a new surgical technique of fovea-sparing internal limiting membrane (ILM) peeling for the treatment of foveal retinal detachments (RDs) in eyes with myopic traction maculopathy. Retrospective, consecutive, interventional case series. Forty-five eyes of 45 consecutive patients who underwent vitrectomy and ILM peeling for the treatment of a foveal RD attributable to myopic traction maculopathy were studied. The patients were divided into 2 groups by the area of ILM peeled: complete macular ILM peeled group (30 eyes) and fovea-sparing ILM peeled group (15 eyes). A gas tamponade was used in all of the eyes. The main outcome measures were the rate of development of a full-thickness macular hole (MH) and the best-corrected visual acuity (BCVA). All of the patients were followed for more than 6 months. A full-thickness MH developed in 5 of 30 eyes (16.7%) in the complete ILM peeled group and in none of the 15 eyes in the fovea-sparing ILM peeled group. Postoperative OCT examination showed a contraction of the residual ILM on the fovea and reduction of the outer lamellar holes in the fovea-sparing ILM peeled group. The postoperative BCVA was significantly better than the preoperative BCVA in the fovea-sparing ILM peeled group (P = .04), but not in the complete ILM peeled group. Fovea-sparing ILM peeling results in better visual and anatomic outcomes for the treatment of foveal RD attributable to myopic traction maculopathy. These were accomplished by reducing the development of a full-thickness MH.

Sequential epiretinal membrane removal with internal limiting membrane peeling in brilliant blue G-assisted macular surgery

PurposeTo assess the selectivity of brilliant blue G (BBG) staining by analysing the morphological components of unstained and stained tissue obtained during epiretinal membrane (ERM) removal with internal limiting membrane...

Double Staining with Brilliant Blue G and Double Peeling for Epiretinal Membranes

To compare methods of removing epiretinal membranes (ERM) and evaluate the usefulness of the double brilliant blue G (BBG) staining and double-peeling method. Prospective, interventional case series. We followed 246 consecutive patients who underwent pars plana vitrectomy to remove ERM and for > or =12 months. Of the 246 eyes, 104 underwent single ERM peeling using indocyanine green staining, and 142 underwent ERM peeling by 1 of the 3 following methods: without staining in 46 eyes, triamcinolone acetonide staining in 42, and BBG staining in 54. Peeling of residual internal limiting membrane (ILM) was then conducted using BBG. In the latter group, the ILM that remained after the initial peeling procedure was evaluated macroscopically with BBG staining and also histopathologically. In 6 eyes requiring reoperation owing to ERM recurrence, the peeled ERM was examined histopathologically. Postoperative visual acuity and recurrence of ERM. The ERM recurrence rate was 16.3% (17 eyes) and the reoperation rate was 5.8% (6 eyes) among the 104 eyes that underwent single ERM peeling, compared with 0% in 142 eyes with double ERM and ILM peeling. Although the ERM recurrence rate was significantly lower with double peeling, postoperative visual acuity did not differ between the 2 methods. The 3 ERM peeling methods differed in the rate and extent of residual ILM, and the lowest rate (21/54 eyes; 39%) was achieved with BBG staining (P<0.0001). Histopathologic examination of the ILM remaining after ERM peeling detected remnant ERM cells on the ILM. Histopathologic examination of the peeled ERM in 6 eyes with ERM recurrence showed residual ILM to serve as a scaffold for cell proliferation. This study verified that ERM recurrence arises from remnant ERM components on the ILM, which proliferate using the ILM as a scaffold, and that complete ILM removal seems to reduce the risk of recurrence. Brilliant blue G with good affinity for the ILM facilitates simultaneous ERM and ILM peeling in many cases, and BBG contact with the retina in the second staining has no apparent effect on visual acuity. Double BBG staining and double peeling is useful for ERM treatment.

Residual internal limiting membrane in epiretinal membrane surgery

Background/aim:To examine the degree of the residual internal limiting membrane (ILM) after epiretinal membrane (ERM) peeling.Methods:Sixty-one eyes of 59 patients with ERM were enrolled. After ERM peeling, residual ILM was...