A Modified Surgical Technique of Fovea-Sparing Internal Limiting Membrane Peeling: Continuous Arc-Shaped Foldback Peeling.
ABSTRACT: Purpose:To investigate the efficacy of management of high myopic foveoschisis (MF) with a modified surgical technique of arc-shaped foldback fovea-sparing internal limiting membrane (ILM) peeling. Methods:A 23-gauge vitrectomy was performed in five patients with high MF. A long strip of ILM was peeled at the temporal side of the central fovea. Next, an ILM forceps was used to grasp the outer side of the ILM flap, and it was moved forward slowly from the outside to the paracentral fovea, followed by folding ILM back in an arc-shaped manner and then removing it. The above operations were repeated, and all ILM flaps were removed from the outside to paracentral fovea until a narrow strip of ILM remained. Finally, the narrow strip of ILM was excised using a vitreous cutter. Results:At the patients' last visits, the foveoschisis almost disappeared completely and the fovea reattached. The central macular thickness statistically decreased from 399.0?±?96.33??m preoperatively to 164.60?±?34.20??m postoperatively (t?=?4.289; P=0.013). The preoperative mean logarithm of the minimum angle of resolution best-corrected visual acuity (1.64?±?0.65) significantly improved to 0.72?±?0.18 postoperatively (t?=?3.265, P=0.031). The average follow-up time was 11.80?±?3.35 months (range; 8-16 months). Conclusion:The arc-shaped foldback fovea-sparing ILM peeling technique for high MF is safe and effective.
Project description:Myopic foveoschisis (MF) is among the leading causes of visual loss in high myopia. However, it remains controversial whether internal limiting membrane (ILM) peeling or gas tamponade is necessary treatment option for MF.PubMed, EMBASE, CBM, CNKI, WANFANG DATA and VIP databases were systematically reviewed. Outcome indicators were myopic foveoschisis resolution rate, visual acuity improvement and postoperative complications.Nine studies that included 239 eyes were selected. The proportion of resolution of foveoschisis was higher in ILM peeling group than non-ILM peeling group (OR = 2.15, 95% CI: 1.06-4.35; P = 0.03). The proportion of postoperative complications was higher in Tamponade group than non-Tamponade group (OR = 10.81, 95% CI: 1.26-93.02; P = 0.03). However, the proportion of visual acuity improvement (OR = 1.63, 95% CI: 0.56-4.80; P = 0.37) between ILM peeling group and non-ILM peeling group and the proportion of resolution of foveoschisis (OR = 1.80, 95% CI: 0.76-4.28; P = 0.18) between Tamponade group and non-Tamponade group were similar.Vitrectomy with internal limiting membrane peeling could contribute to better resolution of myopic foveoschisis than non-peeling, however it does not significantly influence the proportion of visual acuity improvement and postoperative complications. Vitrectomy with gas tamponade is associated with more complications than non-tamponade and does not significantly influence the proportion of visual acuity improvement and resolution of myopic foveoschisis.
Project description:PURPOSE:To investigate the long-term results of a modified technique for parafoveal multiple curvilinear internal limiting membrane (ILM) peeling to preserve the epi-foveal ILM in myopic foveoschisis surgery. METHODS:Thirty-two consecutive patients (36 eyes) were retrospectively reviewed. Patients were divided into two groups according to the extent of ILM peeled: the fovea-sparing ILM peeling group (FS) (18 eyes) and total ILM peeling group (TP) (18 eyes). Patients were followed up for at least 12 months. The main outcome measures were best-corrected visual acuity changes, evolution of macular schisis and the factors associated with the development of a full-thickness macular hole (FTMH). RESULTS:FTMH developed in 1 of 18 eyes (5.6%) in the FS group and 3 of 18 eyes (16.7%) in the TP group (P = 0.28). Long-term follow-up showed visual improvement was better in the FS group than in the TP group (0.94 vs. 0.58 logMAR). Macular schisis disappeared in 13 of 18 eyes (72.2%) in the FS group, but disappeared in 7 of 18 eyes (38.9%) in the TP group (P = 0.04). Logistic regression analysis showed that only the preoperative outer lamellar macular hole (P = 0.016) was a significant risk factor for development of postoperative FTMH. CONCLUSIONS:Fovea-sparing ILM peeling achieves a higher rate of macular schisis resolution over total peeling. A preoperative outer lamellar macular hole can be a risk factor for the development of a macular hole.
Project description:To highlight the differences in macular pigment optical density (MPOD) between eyes with vitreoretinal interface syndrome and healthy control eyes, to assess the changes in MPOD in eyes treated with macular peeling, to investigate the relationships between MPOD changes and measures of retinal sensitivity such as best corrected visual acuity (BCVA) and microperimetry.In this cross-sectional comparative study, 30 eyes affected by idiopathic epiretinal membrane (iERM, 15eyes) or full-thickness macular hole (FTMH, 15eyes) were compared with 60 eyes from 30 healthy age-matched patients. MPOD values (mean MPOD, maximum MPOD, MPOD area, and MPOD volume) were measured in a range of 4°-7° of eccentricity around the fovea, using the one-wavelength reflectometry method (Visucam 200, Carl-Zeiss Meditec). Patients affected by iERM and FTMH were treated with vitrectomy and epiretinal membrane-inner limiting membrane (ERM-ILM) peeling, with follow-up examinations performed preoperatively and 6 months postoperatively. The main outcome measures were the differences in MPOD between eyes with vitreoretinal interface syndrome and healthy eyes, changes in MPOD after ERM-ILM peeling, and relationships between MPOD and functional changes.Mean MPOD differed significantly between control eyes and those with iERM (P = .0001) or FTMH (P = .0006). The max MPOD and MPOD area increased, but not significantly. After peeling, the only significant change in MPOD was in MPOD volume (P = .01). In the ERM group, postoperative mean MPOD correlated significantly with best-corrected visual acuity (r = .739, P = .002).MPOD was reduced in patients with iERM or FTMH compared with healthy eyes. We found a significant correlation between the mean postoperative MPOD and postoperative BCVA, hypothesizing that the postoperative increase in mean MPOD could be due to a change in distribution for unfolding and expansion of the fovea after the peeling. MOPD may be considered as a prognostic factor associated with a good visual prognosis in patients with iERM.
Project description:<h4>Background</h4>Internal limiting membrane (ILM) peeling during primary vitrectomy for rhegmatogenous retinal detachment (RRD) prevents the formation of postoperative macular epiretinal membrane (ERM). However, studies that compared vitrectomy with and without ILM peeling for RRD, have reported controversial outcomes.<h4>Objective</h4>To assess the efficacy of ILM peeling versus non-ILM peeling during vitrectomy for RRD by a systematic review and meta-analysis of published studies.<h4>Methods</h4>PubMed, Medline, Web of Science, Embase databases, and the Cochrane Library were searched up to April 2018 to identify studies that compared primary vitrectomy with and without ILM peeling for RRD with at least six months follow-up. Primary outcomes were the rate of postoperative ERM formation and mean best corrected visual acuity (BCVA) change after vitrectomy. Rate of recurrence of retinal detachment (RD) was assessed as secondary outcome. Risk ratios (RRs) with 95% confidence intervals (CIs) expressed pooled results for rate of ERM formation and rate of RD recurrence in ILM peeling and non-ILM peeling groups. Pooled results for BCVA change in the two groups were expressed as Weighted Mean Difference (WMD) with 95% CIs.<h4>Results</h4>Nine studies, one of which was a randomized controlled trial (RCT), with a total number of 404 eyes in the ILM peeling group and 365 eyes in the non-ILM peeling group, were included. The analysis from pooled data indicated a significant lower rate of postoperative ERM formation in the ILM peeling group compared to the non-ILM peeling group (9 studies, 769 eyes, RR = 0.14; CI: 0.07 to 0.28; P < 0.001). There was no statistical difference in mean BCVA change (9 studies, 769 eyes, WMD = 0.02; CI: -0.11 to 0.16; P = 0.75). Rate of recurrence of RD was lower in the ILM peeling group (6 studies, 603 eyes, RR = 0.32; CI = 0.17 to 0.61; P< 0.001).<h4>Conclusion</h4>ILM peeling during vitrectomy for RRD prevents the formation of macular epiretinal membrane postoperatively and reduces the incidence of RD recurrence, but better visual outcome was not found compared to non-ILM peeling vitrectomy.
Project description:BACKGROUND:The epiretinal membrane (ERM) is a degenerative condition associated with age, which can cause loss of vision and/or metamorphopsia. The treatment of symptomatic ERM involves surgical removal including a vitrectomy followed by peeling of the ERM using a microforceps. As the internal limiting membrane (ILM) is adherent to the ERM, it is sometimes removed with it (spontaneous peeling). If ILM remains in place, it can be removed to reduce ERM recurrence. However, it is important to clarify the safety of ILM peeling, while it increases surgical risks and cause histological disorganization of the retina that can lead to microscotomas, may be responsible for definitive visual discomfort. METHODS:PEELING is a prospective, randomized, controlled, single-blind, and multicentered trial with two parallel arms. This study investigates the benefit/risk ratio of active ILM peeling among individuals undergoing ERM surgery without spontaneous ILM peeling. Randomization is done in the operating room after ERM removal if ILM remains in place. After randomization, the two groups-"active peeling of the ILM" and "no peeling of the ILM"-are compared during a total of three follow-up visits scheduled at month 1, month 6, and month 12. Primary endpoint is the difference in microscotomas before surgery and 6?months after surgery. Patients with spontaneous peeling are not randomized and are included in the ancillary study with the same follow-up visits and the same examinations as the principal study. Relevant inclusion criteria involve individuals aged >?18?years living with idiopathic symptomatic ERM, including pseudophakic patients with transparent posterior capsule or open capsule or lensed patients with age-related cataracts. The calculated sample size corresponds to 53 randomized eyes (one eye/patient) per arm that means 106 randomized eyes (106 randomized patients) in total and a maximum of 222 included patients (116 spontaneous peeling). DISCUSSION:ILM peeling is often practiced in ERM surgery to reduce ERM recurrence. It does not impair postoperative visual acuity, but it increases the surgical risks and causes anatomical damages. If active ILM peeling is significantly associated with more microscotomas, it may contraindicate the ILM peeling during primitive idiopathic ERM surgery. TRIAL REGISTRATION:ClinicalTrials.gov, NCT02146144. Registered on 22 May 2014. Recruitment is still ongoing.
Project description:Studies on vitrectomy with and without internal limiting membrane (ILM) peeling for idiopathic epiretinal membrane (ERM) have yielded uncertain results regarding clinical outcomes and recurrence rates.To compare the clinical outcomes of vitrectomy with and without ILM peeling for idiopathic ERM.Databases, including PubMed, Embase, Cochrane, Web of Science, Google Scholar, CNKI databases, FDA.gov, and ClinicalTrials.gov, published until July 2016, were searched to identify studies comparing the clinical outcomes following vitrectomy with ERM and ILM peeling and with only ERM peeling, for treating idiopathic ERM. Studies with sufficient data were selected. Pooled results were expressed as mean differences (MDs) and risk ratios (RRs) with corresponding 95% confidence intervals (CI) for vitrectomy with and without ILM peeling with regard to postoperative best corrected visual acuity (BCVA), central retinal thickness (CRT), and ERM recurrence rate.Eleven retrospective studies and one randomized controlled trial involving 756 eyes were identified. This demonstrated that the postoperative BCVA within 12 months was significantly better in the non-ILM peeling group (MD = 0.04, 95% CI: 0.00 to 0.08; P = 0.0460), but that the patients in the ILM peeling group had significantly better postoperative BCVA after 18 months (MD = -0.13, 95% CI: -0.23 to -0.04; P = 0.0049) than did those in the non-ILM peeling group. The non-ILM peeling group exhibited a higher reduction in postoperative CRT (MD = 51.55, 95% CI:-84.23 to -18.88; P = 0.0020) and a higher recurrence rate of ERM (RR = 0.34, 95% CI:0.16 to 0.72; P = 0.0048) than did the ILM peeling group. However, the improvement rates of BCVA (RR = 1.03, 95% CI:0.72 to 1.47; P = 0.8802) and postoperative CRTs (MD = 18.15, 95% CI:-2.29 to 38.60; P = 0.0818) were similar between the two groups.Vitrectomy with ILM peeling results in better visual improvement in long-term follow-ups and lower ERM recurrence rates, and vitrectomy with only ERM peeling is more efficacious in reduction of CRT than is vitrectomy with ILM peeling.
Project description:The present study was performed to establish a novel ocular surgery simulator for training in peeling of the inner limited membrane (ILM). This simulator included a next-generation artificial ILM with mechanical properties similar to the natural ILM that could be peeled underwater in the same manner as in actual surgery. An artificial eye consisting of a fundus and eyeball parts was fabricated. The artificial eye was installed in the eye surgery simulator. The fundus part was mounted in the eyeball, which consisted of an artificial sclera, retina, and ILM. To measure the thickness of the fabricated ILM on the artificial retina, we calculated the distance of the step height as the thickness of the artificial ILM. Two experienced ophthalmologists then assessed the fabricated ILM by sensory evaluation. The minimum thickness of the artificial ILM was 1.9 ± 0.3 ?m (n = 3). We were able to perform the peeling task with the ILM in water. Based on the sensory evaluation, an ILM with a minimum thickness and 1000 degrees of polymerization was suitable for training. We installed the eye model on an ocular surgery simulator, which allowed for the performance of a sequence of operations similar to ILM peeling. In conclusion, we developed a novel ocular surgery simulator for ILM peeling. The artificial ILM was peeled underwater in the same manner as in an actual operation.
Project description:RATIONALE:Managing retinal detachment due to posterior retinal holes is problematic since standard laser retinopexy or scleral buckling may be difficult to apply and may have brought serious complication. Another surgical method in treating posterior hole related retinal detachment is desired. PATIENT CONCERNS:Three high myopia patients with previous vitrectomy and membrane peeling history suffered from blurred vision and retinal detachment due to posterior pole retinal holes was diagnosed. DIAGNOSES:Patient diagnosed retinal detachment due to posterior retinal holes either as paracentral retinal breaks or macular hole from both indirect ophthalmoscope exam and fundus photography INTERVENTIONS:: The patient underwent lens capsular flap insertion into all the retinal holes, along with gas tamponade or silicone oil tamponade. No laser retinopexy was performed around the retinal holes. OUTCOMES:Of 3 included patients, 1 patient had insertion of the lens capsular flap, an incomplete air-fluid exchange, and 24% sulfur hexafluoride gas tamponade. The other 2 patients, after lens capsular flap insertion, had air-fluid exchange and subretinal fluid drainage with extrusion via soft needle through superior drainage retinotomy and silicon oil tamponade. The retinal holes of all eyes were sealed with retina attached postoperatively. LESSONS:Lens capsular flap is effective in sealing posterior retinal holes and treating the associated retinal detachment without the complication resulting from laser retinopexy, especially in eyes without sufficient internal limiting membrane (ILM) tissue due to previous ILM peeling.
Project description:Differences in the pathogenesis and clinical characteristics between lamellar macular hole (LMH) with and without LMH-associated epiretinal proliferation (LHEP) can have surgical implications. This study investigated the effects of treating LHEP by foveolar internal limiting membrane (ILM) non-peeling and epiretinal proliferative (EP) tissue repositioning on visual acuity and foveolar architecture. Consecutive patients with LHEP treated at our institution were enrolled. The eyes were divided into a conventional total ILM peeling group (group 1, n?=?11) and a foveolar ILM non-peeling group (group 2, n?=?22). In group 2, a doughnut-shaped ILM was peeled, leaving a 400-?m-diameter ILM without elevated margin over the foveola after EP tissue repositioning. The EP tissue was elevated, trimmed, and inverted into the LMH. Postoperatively, the LMH was sealed in all eyes in group 2, with significantly better best-corrected visual acuity (-0.26 vs -0.10 logMAR; p?=?0.002). A smaller retinal defect (p?=?0.003), a more restored ellipsoid zone (p?=?0.002), and a more smooth foveal depression (p?<?0.001) were achieved in group 2. Foveolar ILM non-peeling and EP tissue repositioning sealed the LMH, released the tangential traction, and achieved better visual acuity. The presumed foveolar architecture may be reconstructed surgically. LMH with LHEP could have a combined degenerative and tractional mechanism.
Project description:BACKGROUND:A full-thickness macular hole (FTMH) is a common retinal condition associated with impaired vision. Randomised controlled trials (RCTs) have demonstrated that surgery, by means of pars plana vitrectomy and post-operative intraocular tamponade with gas, is effective for stage 2, 3 and 4 FTMH. Internal limiting membrane (ILM) peeling has been introduced as an additional surgical manoeuvre to increase the success of the surgery; i.e. increase rates of hole closure and visual improvement. However, little robust evidence exists supporting the superiority of ILM peeling compared with no-peeling techniques. The purpose of FILMS (Full-Thickness Macular Hole and Internal Limiting Membrane Peeling Study) is to determine whether ILM peeling improves the visual function, the anatomical closure of FTMH, and the quality of life of patients affected by this disorder, and the cost-effectiveness of the surgery. METHODS/DESIGN:Patients with stage 2-3 idiopathic FTMH of less or equal than 18 months duration (based on symptoms reported by the participant) and with a visual acuity </= 20/40 in the study eye will be enrolled in this FILMS from eight sites across the UK and Ireland. Participants will be randomised to receive combined cataract surgery (phacoemulsification and intraocular lens implantation) and pars plana vitrectomy with postoperative intraocular tamponade with gas, with or without ILM peeling. The primary outcome is distance visual acuity at 6 months. Secondary outcomes include distance visual acuity at 3 and 24 months, near visual acuity at 3, 6, and 24 months, contrast sensitivity at 6 months, reading speed at 6 months, anatomical closure of the macular hole at each time point (1, 3, 6, and 24 months), health related quality of life (HRQOL) at six months, costs to the health service and the participant, incremental costs per quality adjusted life year (QALY) and adverse events. DISCUSSION:FILMS will provide high quality evidence on the role of ILM peeling in FTMH surgery. TRIAL REGISTRATION:This trial is registered with Current Controlled Trials ISRCTN number 33175422 and Clinical Trials.gov identifier NCT00286507.