Indocyanine green-assisted internal limiting membrane peeling in macular hole surgery: a meta-analysis

Consensus Conference Statement on the General Use of Near-infrared Fluorescence Imaging and Indocyanine Green Guided Surgery: Results of a Modified Delphi Study

BACKGROUND

In recent decades, the use of near-infrared light and fluorescence-guidance during open and laparoscopic surgery has exponentially expanded across various clinical settings. However, tremendous variability exists in how it is performed.

OBJECTIVE

In this first published survey of international experts on fluorescence-guided surgery, we sought to identify areas of consensus and nonconsensus across 4 areas of practice: fundamentals; patient selection/preparation; technical aspects; and effectiveness and safety.

METHODS

A Delphi survey was conducted among 19 international experts in fluorescence-guided surgery attending a 1-day consensus meeting in Frankfurt, Germany on September 8th, 2019. Using mobile phones, experts were asked to anonymously vote over 2 rounds of voting, with 70% and 80% set as a priori thresholds for consensus and vote robustness, respectively.

RESULTS

Experts from 5 continents reached consensus on 41 of 44 statements, including strong consensus that near-infrared fluorescence-guided surgery is both effective and safe across a broad variety of clinical settings, including the localization of critical anatomical structures like vessels, detection of tumors and sentinel nodes, assessment of tissue perfusion and anastomotic leaks, delineation of segmented organs, and localization of parathyroid glands. Although the minimum and maximum safe effective dose of ICG were felt to be 1 to 2 mg and >10 mg, respectively, there was strong consensus that determining the optimum dose, concentration, route and timing of ICG administration should be an ongoing research focus.

CONCLUSIONS

Although fluorescence imaging was almost unanimously perceived to be both effective and safe across a broad range of clinical settings, considerable further research remains necessary to optimize its use.

Noninfectious Endophthalmitis Following Intraoperative Indocyanine Green

BACKGROUND AND OBJECTIVE

The purpose of this article is to describe a cluster of four cases of severe postoperative inflammation in eyes that received intraoperative indocyanine green (ICG) from the same lot.

PATIENTS AND METHODS

This was a retrospective chart review of patients from a single-center, retina-only group practice. The ICG lot associated with the inflammatory events was identified and analyzed with high-performance liquid chromatography with UV spectroscopy.

RESULTS

Four patients presented on postoperative day 1 with severe inflammation. The first patient was treated with aqueous biopsy and injection of intravitreal antibiotics, followed by topical steroid and antibiotic drops. The subsequent three patients were treated with topical steroid and antibiotic drops. All patients had resolution of inflammation by postoperative day 14 (range 10 to 14 days). High-performance liquid chromatography with UV spectroscopy failed to identify a contaminant.

CONCLUSIONS

The use of intravitreal ICG dye as a surgical adjuvant may uncommonly be associated with severe postoperative inflammation. This inflammation may resolve within weeks after topical corticosteroid and antibiotic treatment. [Ophthalmic Surg Lasers Imaging Retina. 2022;53:148-151.].

Factors Associated with Anatomic Failure and Hole Reopening after Macular Hole Surgery

A macular hole (MH), particularly an idiopathic macular hole (IMH), is a common cause of central vision loss. Risk factors for nonidiopathic MH include high myopia, cystoid macular edema, inflammation, and trauma. MH is primarily diagnosed using slit-lamp microscopy and optical coherence tomography (OCT). Half of the patients with stage I MHs are treated conservatively and may show spontaneous resolution. The main treatment methods for MHs currently include vitrectomy and stripping of the internal limiting membrane (ILM). However, in some patients, surgery does not lead to anatomical closure. In this review, we summarize the factors influencing the anatomical closure of MHs and analyze the potential underlying mechanisms.

Long-Term Outcomes of Macular Hole Repair with Triamcinolone Acetonide Visualization

Purpose

To evaluate the long-term anatomic and visual outcomes of macular hole (MH) repair utilizing triamcinolone acetonide (TA) visualization of the internal limiting membrane (ILM) treated at a tertiary care retina practice.

Methods

Retrospective chart review of eyes undergoing MH repair with ILM peel utilizing TA visualization followed by gas tamponade and facedown positioning between 2014 and 2020. Pre- and post-operative visual acuity (VA), IOP, and anatomic closure based on optical coherence tomography were documented.

Results

Seventy-eight eyes were followed for 2.3±0.2 years after primary repair with anatomic closure in 73 (94%) eyes at their final visit and excluding eyes with pathologic myopia, 97%, and for stage 2 and small MHs, 100%. In all eyes, VA significantly improved from 0.97±0.04 (Snellen: 20/187) to 0.66±0.06 (20/91) logMAR (p < 0.0001). There were 16 eyes with 4 years of follow-up, 10 (63%) eyes achieving a VA ≥20/30 at that follow-up visit. Stage 2 and 3 MHs had significantly greater improvements in VA than Stage 4 MHs, −0.46 ± 0.06 versus −0.11 ± 0.11 logMAR (p = 0.021). Of the 13 (17%) eyes with recurrent MHs, 6 (46%) had pathologic myopia and 8 (61.5%) had associated cystoid macular edema. Cataract progression was reported in 52 (96%) phakic eyes and 2 eyes required Ahmed valve placement for management of pre-existing glaucoma.

Conclusion

Long-term results of MH repair with TA for ILM visualization demonstrate that it is safe and effective. Visual acuity continued to improve throughout the follow-up. Pre-existing glaucoma may progress and recurrence is associated with pathologic myopia and macular edema.

Internal limiting membrane peeling with different dyes in the surgery of idiopathic macular hole: a systematic review of literature and network Meta-analysis

AIM

To evaluate the effect of internal limiting membrane (ILM) peeling with indocyanine green (ICG), brilliant blue G (BBG), triamcinolone acetonide (TA), trypan blue (TB), or without dye for the treatment of idiopathic macular hole (IMH).

METHODS

A search was conducted using PubMed, EMBASE, and CENTRAL (Cochrane Central Register of Controlled Trials) for related studies published before October 2018.

RESULTS

A total of 29 studies and 2514 eyes were included in this network Meta-analysis. For IMH closure, the rank from the best to the worse treatment was: BBG, TB, TA, ICG, and no dye. There was a significant difference in postoperative IMH closure rate between BBG and no dye. The rank of the best to the worse treatment to improve visual acuity was: BBG, TB, no dye, TA, and ICG. The improvement rate of visual acuity after using BBG was significantly higher than ICG. The improvement rate of visual acuity was more favorable with TB than ICG, TA, and no dye.

CONCLUSION

BBG can contribute to better anatomical and functional outcomes compared to other dyes for ILM peeling in patients with IMH. The results show that the best treatment of ILM peeling with dyes is BBG.

[Vitreomacular Interface Diseases: Vitreomacular Adhesion, Vitreomacular Traction, Epiretinal Membranes, and Macular Hole]

Posterior vitreous detachment (PVD) is a common phenomenon in the aging eye. This review presents the sequence of events due to complicated persistent symptomatic vitreomacular adhesions that exert tractional forces on the macula (vitreomacular traction, VMT; macular hole, MH; epiretinal membrane). Pathologic aspects, clinical features, diagnostic implications, and current management strategies are described. Observation, pharmacologic vitreolysis with Ocriplasmin, and surgical treatment are positioned as treatment options for different diseases.

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.].

A Review of Surgical Outcomes and Advances for Macular Holes

The surgical outcomes of macular holes (MHs) have improved greatly in recent years. The closure rate is as high as 90-100%, but the outcomes of some special types of MHs remain unsatisfactory. Internal limiting membrane (ILM) peeling dramatically improves the anatomic success rate, but recent studies have found that it could also cause mechanical and subclinical traumatic changes to the retina. Dyes are widely used, and apart from indocyanine green (ICG), the toxicities of other dyes require further research. Face-down posturing is necessary for MHs larger than 400 μm, and the duration of this posture is determined by the type of tamponade and the case. The ellipsoid zone has been shown to be highly correlated with visual outcome and recovery. New surgical methods include the inverted ILM flap technique and the ILM abrasion technique. However, they require further research to determine their effectiveness.

Macular Hole Surgery with Internal Limiting Membrane Peeling Facilitated by Membrane-Blue® versus Membrane-Blue-Dual®: A Retrospective Comparative Study

Background. This study aims to compare the outcome of macular hole (MH) surgery with internal limiting membrane (ILM) peeling facilitated by two different vital dyes. Methods. This was a retrospective chart review. The group designated “group-MB” underwent pars plana vitrectomy with ILM peeling facilitated by Membrane-Blue (MB), whereas in “group-MBD,” the vital dye used was Membrane-Blue-Dual (MBD). Results. Seventy-four eyes comprised the study population: 53 in group-MB and 21 in group-MBD. There was no difference in the rate of macular hole closure in group-MB or group-MBD: 71.2% closed MHs compared to 66.7%, respectively (p = 0.7). Postoperative visual improvement was of a higher magnitude in the MBD group compared to the MB group: −0.34 ± 0.81 logMAR versus 0.01 ± 0.06 logMAR, respectively (p = 0.003). Conclusions. In this study, MBD led to better visual results that may be related to better staining characteristics or lesser toxicity compared to MB.

Live volumetric (4D) visualization and guidance of in vivo human ophthalmic surgery with intraoperative optical coherence tomography

Minimally-invasive microsurgery has resulted in improved outcomes for patients. However, operating through a microscope limits depth perception and fixes the visual perspective, which result in a steep learning curve to achieve microsurgical proficiency. We introduce a surgical imaging system employing four-dimensional (live volumetric imaging through time) microscope-integrated optical coherence tomography (4D MIOCT) capable of imaging at up to 10 volumes per second to visualize human microsurgery. A custom stereoscopic heads-up display provides real-time interactive volumetric feedback to the surgeon. We report that 4D MIOCT enhanced suturing accuracy and control of instrument positioning in mock surgical trials involving 17 ophthalmic surgeons. Additionally, 4D MIOCT imaging was performed in 48 human eye surgeries and was demonstrated to successfully visualize the pathology of interest in concordance with preoperative diagnosis in 93% of retinal surgeries and the surgical site of interest in 100% of anterior segment surgeries. In vivo 4D MIOCT imaging revealed sub-surface pathologic structures and instrument-induced lesions that were invisible through the operating microscope during standard surgical maneuvers. In select cases, 4D MIOCT guidance was necessary to resolve such lesions and prevent post-operative complications. Our novel surgical visualization platform achieves surgeon-interactive 4D visualization of live surgery which could expand the surgeon’s capabilities.

Face-down or no face-down posturing following macular hole surgery: a meta-analysis

PURPOSE

To evaluate the impact of postoperative posturing with or without face-down on the anatomical and functional outcomes of macular hole surgery.

METHODS

A literature-based meta-analysis was conducted to identify studies relevant to posturing following macular hole surgery (MHS). PubMed and Web of Science databases were used to retrieve articles up to 1 June 2015. The primary measures included MH closure and ideal vision acuity improvement. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were estimated in Review Manager.

RESULTS

Four randomized control trials (RCTs) comprising 251 cases were included in the final meta-analysis. No face-down posturing (FDP) after MHS revealed lower anatomic success rate compared to face-down posturing (OR = 0.33, 95% CI [0.13, 0.81], p = 0.02). For holes smaller than 400 μm in size, the subgroup meta-analysis indicated no significant effect of FDP on successful hole closure (OR = 0.29, 95% CI [0.01, 7.34], p = 0.45). However, when holes were larger than 400 μm, it seemed less effective on MH closure following surgery in no FDP group (OR = 0.23, 95% CI [0.07, 0.71]), and this was statistically significant (p = 0.01).

CONCLUSIONS

Our work found that no FDP was not inferior to its face-down counterpart for the success of MHS when macular holes were smaller than 400 μm in size. For macular holes larger than 400 μm, statistical analysis proved that FDP might be necessary. More well-conducted randomized control trials are needed to verify our findings.

Optimal management of idiopathic macular holes

This review evaluates the current surgical options for the management of idiopathic macular holes (IMHs), including vitrectomy, ocriplasmin (OCP), and expansile gas use, and discusses key background information to inform the choice of treatment. An evidence-based approach to selecting the best treatment option for the individual patient based on IMH characteristics and patient-specific factors is suggested. For holes without vitreomacular attachment (VMA), vitrectomy is the only option with three key surgical variables: whether to peel the inner limiting membrane (ILM), the type of tamponade agent to be used, and the requirement for postoperative face-down posturing. There is a general consensus that ILM peeling improves primary anatomical hole closure rate; however, in small holes (<250 µm), it is uncertain whether peeling is always required. It has been increasingly recognized that long-acting gas and face-down positioning are not always necessary in patients with small- and medium-sized holes, but large (>400 µm) and chronic holes (>1-year history) are usually treated with long-acting gas and posturing. Several studies on posturing and gas choice were carried out in combination with ILM peeling, which may also influence the gas and posturing requirement. Combined phacovitrectomy appears to offer more rapid visual recovery without affecting the long-term outcomes of vitrectomy for IMH. OCP is licensed for use in patients with small- or medium-sized holes and VMA. A greater success rate in using OCP has been reported in smaller holes, but further predictive factors for its success are needed to refine its use. It is important to counsel patients realistically regarding the rates of success with intravitreal OCP and its potential complications. Expansile gas can be considered as a further option in small holes with VMA; however, larger studies are required to provide guidance on its use.

Idiopathic vitreomacular traction and macular hole: a comprehensive review of pathophysiology, diagnosis, and treatment

Posterior vitreous detachment (PVD) is a common phenomenon in the aging eye. However, this may be complicated by persistent symptomatic vitreomacular adhesions that exert tractional forces on the macula (vitreomacular traction; VMT). VMT itself may be associated with epiretinal membrane formation and the development of idiopathic macular holes (IMH). Such pathologies may cause visual disturbances, including metamorphopsia, photopsia, blurred vision, and decreased visual acuity, which impact an individual's quality of life. Technologies such as optical coherence tomography allow an increasingly more accurate visualisation of the macular anatomy, including quantification of macular hole characteristics, and this facilitates treatment decision-making. Pars plana vitrectomy remains the primary treatment option for many patients with VMT or IMH; for the latter, peeling of the inner limiting membrane (ILM) of the retina has shown improved outcomes when compared with no ILM peeling. The development of narrow-gauge transconjunctival vitrectomy systems has improved the rate of visual recovery following surgery. Ocriplasmin, by degrading laminin and fibronectin at the vitreoretinal interface, may allow induction of PVD in a non-invasive manner. Indeed, clinical studies have supported its use as an alternative to surgery in certain patient populations. However, further research is still needed with respect to greater understanding of the pathophysiology underlying the development of VMT and IMH.

Predicting visual outcome following surgery for idiopathic macular holes

Since Kelly and Wendel [Arch Ophthalmol 1991;109:654-659] first reported successfully treating macular holes (MHs) using pars plana vitrectomy in 1991, MH surgery has been constantly improved. For example, introducing the removal of the internal limiting membrane considerably increased the closure rate of MHs, and the advent of microincision vitrectomy surgery reduced surgical trauma and decreased patient discomfort after surgery. As modern MH surgery can achieve a higher anatomical success rate and alleviate patients' postoperative distress, postoperative visual outcomes have lately become the primary concern. Informing patients of the expected visual acuity and visual improvement before surgery is ideal, but predicting postoperative visual outcomes is difficult because a large number of factors are associated with them. In this paper, we review previous studies and provide accumulating evidence for the relationship between individual prognostic factors and visual outcomes after MH surgery.

Morphological and functional outcome after brilliant blue G-assisted macular hole surgery

PURPOSE OF THE STUDY

To investigate the outcome of brilliant blue G (BBG)-assisted internal limiting membrane peeling in macular hole surgery after a follow-up of 6 months.

PROCEDURES

In this retrospective study 20 eyes have been treated with BBG-assisted macular hole surgery. After a follow-up of 6 months, the functional and anatomical outcomes have been analyzed.

RESULTS

The mean preoperative best-corrected visual acuity (BCVA) was 0.7 logMAR units (mean ± SD 0.66 ± 0.27). After 3 months, the mean BCVA increased not significantly to 0.4 (0.54 ± 0.30), but a significant improvement to 0.2 logMAR units (0.28 ± 0.23) could be detected after 6 months compared to baseline (p < 0.01). Primary macular hole closure after a single surgery was found in 17 of 20 eyes.

CONCLUSION AND MESSAGE

BBG exhibits sufficient staining qualities and safety profile leading to a significant functional improvement after successful macular hole surgery.