A useful technique of starting internal limiting membrane peeling from the edge of the internal limiting membrane defect in epiretinal membrane surgery

Clinicians should be aware that internal limiting membrane (ILM) defects may occur concurrently with epiretinal membrane, and starting ILM peeling at the ILM defect margin may be useful in such cases.

Abstract

We describe a useful surgical technique for the treatment of idiopathic epiretinal membrane with concurrent internal limiting membrane (ILM) defect, in which ILM peeling was started from the ILM defect margin. A dissociated optic nerve fiber layer-like appearance on fundus examination and optical coherence tomography may suggest an ILM defect.

Long-term follow-up of retinal sensitivity assessed by microperimetry in patients with internal limiting membrane peeling

PURPOSE

To evaluate anatomical and functional changes in patients with vitreomacular interface disease after internal limiting membrane (ILM) peeling, using microperimetry along with usual clinical and multimodal retinal imaging.

METHODS

Patients with vitreomacular interface disease requiring vitrectomy underwent multimodal retinal evaluation, including visual acuity assessment, fundus color photograph, Spectral-Domain Optical Coherence Tomography, Optical Coherence Tomography-Angiography, and microperimetry. They were examined at baseline (M0), 6 months (M6) and 18 months (M18) after surgery. Retinal sensitivity was subdivided into three concentric polygons: Large, Medium, Small.

RESULTS

Eleven eyes of 11 patients were analyzed, including 10 epiretinal membranes (ERMs). Best-corrected visual acuity (BCVA) improved in all patients from 0.51 logarithm of the minimal angle of resolution (logMAR) to 0.067 (p = 0.0074). Retinal sensitivity improved between M0 and M6 in all polygons and continued to improve between M6 and M18 for polygons Medium (M) and Small (S) with no statistical significance. At M18, BCVA and retinal sensitivity were similar in the operated eye compared with the fellow eye for all patients. Dissociated optic nerve fiber layer appearance was observed in 8 patients at M18. It was not correlated with either retinal sensitivity or BCVA or microscotomas. No recurrence of ERM or macular hole occurred during follow-up.

CONCLUSION

After surgery, the retinal sensitivity assessed by microperimetry gradually improved until the 18th month and was not different from the values of the fellow eye. These results seemed to confirm that ILM peeling can be an effective and safe technique to treat patients with vitreomacular interface disease.

Prognostic factors of idiopathic epiretinal membrane surgery and evolution of alterations of the central cone bouquet

PURPOSE

To describe the structural changes observed postoperatively in epiretinal membranes (ERM), in particular the alterations in the central cone bouquet (CB), and to identify prognostic factors that might predict postoperative outcome.

METHODS

We included 125 eyes of 117 patients who underwent idiopathic ERM removal with at least a 6-month follow-up. For each patient, spectral-domain optical coherence tomography (SD-OCT) was performed and best-corrected visual acuity (BCVA) was measured, before and after surgery.

RESULTS

Before surgery, 44 eyes (35.2%) presented CB alterations: 65.9% a cotton ball sign, 15.9% a foveolar detachment and 18.2% a pseudovitelliform lesion. Median BCVA increased from 20/63 to 20/32 post-operatively (p = .001) with a mean follow-up of 17 months. The disappearance of CB alterations after surgery was observed in 97.7% of eyes. In stage 3 and 4 ERM, ectopic inner foveal layers persisted in 76.7% of eyes after surgery. Postoperative BCVA was correlated with change in central macular thickness and initial BCVA and was not correlated with the presence of preoperative CB alteration, the initial stage of ERM, the presence of postoperative dissociated optical nerve fiber layer, and the disappearance of ectopic inner fiber layers. The combination of cataract surgery and capsulotomy did not seem to change visual outcome and seemed to accelerate visual recovery. Incidentally, general anesthesia was correlated with final BCVA.

CONCLUSION

ERM surgery allowed a significant gain in BCVA and the disappearance of CB alterations in the great majority of cases. CB alteration did not show to be associated with poor visual prognosis.

Vital Dyes in Vitreomacular Surgery

Vital dyes contain complex molecules with chromophores that stain living tissues and have greatly enhanced identification and removal of transparent vitreoretinal tissues during surgery. Several "chromovitrectomy" dyes are frequently used by vitreoretinal specialists, including indocyanine green, trypan blue, brilliant blue G, and triamcinolone acetonide; other dyes are also under investigation. Trypan Blue was approved by the U.S. Food and Drug Administration (FDA) for epiretinal membrane removal, and preservative-free triamcinolone acetonide was approved by the FDA for intraocular use. However, currently available chromovitrectomy dyes have their limitations, and of particular concern for some of them is the possibility for acute and chronic toxicity to the neurosensory retina and retinal pigmented epithelium. The potentially irreversible acute toxicity and other limitations, such as lack of long-term safety profiles, highlight the need for further advancements. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:788-798.].

The role of the optical coherence tomography in identifying shape and size of idiopathic epiretinal membranes

AIM

Currently, the border of idiopathic epiretinal membranes (iERM) is outlined intraoperatively using vital dyes. Therefore, the authors set out to investigate the role of the preoperative retinal thickness map (RTM) of the optical coherence tomography (OCT) in identifying the shape and the size of the iERMs.

Methods

15 eyes of 15 patients with iERM who underwent vitrectomy with indocyanine green-assisted membrane peeling were included in this study. The authors analysed the intraoperative fundus images and preoperative Cirrus HD-OCT to detect the shape and the size of the iERM as well as the shape and the size of each thickness-indicating colour (white, red, orange and yellow) on the RTM, respectively. The correlation of areas and morphologic characteristics between both groups was explored.

Results

Analysis of iERM morphologic characteristics (shape) showed a similarity between the iERM contour and the corresponding RTM in 13 cases (86.6%). Furthermore, retinal folds were found in six iERMs and in their corresponding RTMs. Analysis of iERM size (area) revealed a positive correlation between the iERM area and each studied coloured area in RTM. The most significant correlation was between iERM and the red area (440–480 μm; r=0.87, p<0.0001).

Conclusion

The iERM-related retinal folds are clearly distinguishable on the HD-OCT. The red area in RTM representing the 440–480 μm retinal thickness can be a reliable predictor of the extent and the shape of the iERM.

Low-Concentration Infracyanine Green–Assisted Internal Limiting Membrane Peeling in Idiopathic Macular Pucker 25-Gauge Surgery

Purpose

To investigate the efficacy of 25-gauge infracyanine green–assisted idiopathic macular pucker surgery and to identify prognostic factors.

Methods

In this retrospective interventional case series, 83 patients with idiopathic macular pucker who underwent 25-gauge surgery with infracyanine green–assisted internal limiting membrane (ILM) peeling were retrospectively reviewed. Best-corrected visual acuity (BCVA) measurement, complete ophthalmologic evaluation, and optical coherence tomography were performed at baseline and during follow-up. Preoperative and postoperative prognostic factors were correlated with final visual outcomes.

Results

Mean follow-up was 10.5 months (range 3-44). Best-corrected visual acuity improved from 0.56±0.27 logMAR (±SD) to 0.26 ±0.18 logMAR (p<0.001); central retinal thickness decreased from 441±115 μm to 355±72 μm (p<0.001). Greater postoperative visual gain was correlated with baseline BCVA (r=–0.65, p<0.0001), and BCVA gain after 1 week (r=0.64, p<0.0001) and 1 month (r=0.58, p<0.0001). Final BCVA was influenced by baseline BCVA (r=0.46, p<0.0001), BCVA change after 1 month (r=0.34, p=0.002), and presence of intraretinal fluid (r=0.28, p=0.01). No cases of endophthalmitis, retinal tears, or retinal detachments were reported.

Conclusions

Low-concentration infracyanine green–assisted ILM peeling during minimally invasive surgery is associated with significant visual acuity improvement. Preoperative BCVA and optical coherence tomography appearance may be helpful in predicting the final visual outcome.

Vitrectomy for idiopathic epiretinal membrane in elderly patients: surgical outcomes and visual prognosis

PURPOSE

To evaluate the clinical course and visual prognosis of elderly patients over 75 years of age who underwent PPV and peeling of idiopathic ERM.

DESIGN

Retrospective case series.

METHODS

A retrospective chart review of patients that underwent vitrectomy for idiopathic ERM in two public hospitals. Twenty nine eyes of 29 patients 75 years and older who underwent PPV and ERM peeling were included in the study series. Patients with additional ocular vision-limiting conditions other than cataract were excluded. Main outcome measures included VA improvement, OCT changes and complications.

RESULTS

Mean patient age was 79.6 years, the highest in published literature. Mean change in VA was 0.23 logMAR units, and 65.5% patients gained 2 or more lines of vision. Eight of the 10 patients aged 80 years or older gained 2 lines or more. Fourteen patients (48.3%) achieved final VA of 20/40 or better, and only 2 (6.9%) had final VA of 20/200 or worse. Concurrent cataract extraction was performed in 73% of the phakic eyes, and at the end of the follow up 93% were pseudophakic. Complication rates were similar to those reported in the literature.

CONCLUSIONS

Pars plana vitrectomy with ERM peeling is safe and effective in restoring VA in elderly patients, and the results are comparable to those previously reported for younger patients with idiopathic ERM. Old age should not hinder surgery in patients with idiopathic ERM who seek to improve their vision and quality of life.