Effects of vitrectomy combined with internal limiting membrane peeling in patients with diabetic macular edema

BACKGROUND Diabetic macular edema(DME),a chronic microvascular complication of diabetes,is a leading cause of visual impairment and blindness.Pars plana vitrectomy(PPV)can restore the normal macular structure and reduce macular edema,whereas internal limiting membrane(ILM)peeling is used to treat tractional macular diseases.Despite the advantages,there is limited research on the combined effects of PPV with ILM peeling.AIM To observe the effects of PPV combined with ILM peeling on postoperative central macular thickness(CMT),best-corrected visual acuity(BCVA),cystoid macular edema(CME)volume,and complications in patients with DME.METHODS Eighty-one patients(92 eyes)diagnosed with DME at the Beijing Shanqu Liangxiang Hospital between January and December 2022 were randomly divided to undergo PPV alone(control group:41 patients,47 eyes)or PPV+ILM peeling(stripping group:40 patients,45 eyes);a single surgeon performed all surgeries.The two groups were compared preoperatively and 1 and 3 months postoperatively.RESULTS Preoperatively,both groups had comparable values of CMT,BCVA,and CME volume(P>0.05).After surgery(both 1 and 3 months),both groups showed significant reductions in CMT,BCVA,and CME volume compared to preoperative levels,with the stripping group showing more significant reductions compared to the control group(P<0.05).Further repeated-measures ANOVA analysis for within-group differences revealed significant effects of group and time,and interaction effects for CMT,BCVA,and CME volume(P<0.05).There were no significant differences in the incidence of complications between the groups(retinal detachment:control=2,stripping=1;endophthalmitis:Control=4,stripping=1;no cases of secondary glaucoma or macular holes;χ^(2)=0.296,P=0.587).CONCLUSION PPV with ILM peeling can significantly improve the visual acuity of patients with DME,reduce CMT,and improve CME with fewer complications.

Displacement of the retina after idiopathic macular hole surgery with different internal limiting membrane peeling patterns

AIM:To explore retinal displacement after surgical treatment for idiopathic macular hole(IMH)with different internal limiting membrane(ILM)peeling patterns.METHODS:Totally 22 eyes from 20 patients with IMH were randomly allocated into two groups,N-T group(11 eyes)and T-N group(11 eyes).For patients in N-T group,ILM was peeled off from nasal to temporal retina.For patients in T-N group,ILM was peeled off from temporal to nasal retina.Preoperative,postoperative 1,3,and 6 mo,autofluorescence fundus images were collected for manual measurement of distances of fixed nasal(N),temporal(T),superior(S),and inferior(I)retinal points(bifurcation or crossing of retinal vessels)around the macula to the optic disc(OD).These were respectively defined as N-OD,T-OD,S-OD,and I-OD.The retinal displacement,macular holeclosure rate,and best corrected visual acuity(BCVA)were compared between the two groups after surgery.RESULTS:At postoperative 1,3,and 6 mo,the macula slipped toward the OD,manifested by the decreased T-OD,N-OD,S-OD,and I-OD(P<0.05).No significant difference was found in the T-OD,N-OD,S-OD,and I-OD between N-T group and T-N group.IMH closure rate was 100%both in N-T group and T-N group.There was no significant difference in BCVA between two groups(P<0.05).CONCLUSION:The macula slips toward the OD after successful macular hole surgery.The two different ILM peeling pattern show similar visual outcome and retinal displacement,which means ILM peeling directions are not the influencing factor of postoperative retinal displacement.

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 Pub Med, 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.

A novel surgical technique of internal limiting membrane peeling for high myopic foveoschisis:a wide range of whole piece consecutive peeling without preservation of epi-fovea

AIM:To demonstrate an improved surgical technique of whole piece consecutive internal limiting membrane(ILM) peeling without preservation of the epi-fovea to treat high myopic foveoschisis(MF).METHODS:A 23-gauge 3-port pars plana vitrectomy was performed on 16 patients with high MF.A parallel arc line along the vascular arcades was scraped out with a curved membrane scraper DSP.Next,an ILM forceps was used to catch hold of the incisal edge of the ILM flap,and the action of releasing and separating was subsequently taken toward the direction of the macular fovea.Next,the ILM forceps was used to grasp the released area,and the whole area coherent ILM peeling covering the macular fovea was implemented thereafter.Finally,the ILM was folded backwards and peeled off in the arc direction.RESULTS:At the final visit,the average central macular thickness decreased remarkably from 423.76±177.67 to 178.24±66.21 μm.The mean logarithm of the minimum angle of resolution best-corrected visual acuity of 1.37±0.59 was significantly alleviated to 0.74±0.59.CONCLUSION:The wide range of whole piece consecutive ILM peeling without preservation of the epifovea is proven to be effective and significantly reduced the occurrence of retinal tear and macular hole.

Internal limiting membrane flap technique in macular hole surgery

Vitrectomy combined with internal limiting membrane(ILM)peeling is popular for the treatment of macular hole(MH).However,the improvements of MH closure rate and postoperative visual acuity are not satisfactory especially in large and refractory MHs.Currently,the ILM flap technique has gradually been applied for the treatment of MH and achieved high MH closure rate.The ILM flap technique has many variations,including the difference of the size,shape,number,and manner in which the flaps put on the MHs.The ILM flap technique also has some auxiliary means including perfluoro-n-octane(PFO),dye,autologous blood and adhesive viscoelastics.There is controversy about the effects between several technique variations of ILM flap,and it needs to be explored in the future.

Retinal displacement after surgery for idiopathic macular hole

AIM:To review and summarize the mechanism hypothesis,influencing factors and possible consequences of macular retinal displacement after idiopathic macular hole(IMH)surgery.METHODS:PubMed and Web of Science database was searched for studies published before April 2023 on“Retinal displacement”,“Idiopathic macular holes”,and“Macular displacement”.RESULTS:Recently,more academics have begun to focus on retinal displacement following idiopathic macular holes.They found that internal limiting membrane(ILM)peeling was the main cause of inducing postoperative position shift in the macular region.Moreover,several studies have revealed that the macular hole itself,as well as ILM peeling method,will have an impact on the result.In addition,this phenomenon is related to postoperative changes in macular retinal thickness,cone outer segment tips line recovery,the occurrence of dissociated optic nerve fiber layer(DONFL)and the degree of metamorphopsia.CONCLUSION:As a subclinical phenomenon,the clinical significance of postoperative macular displacement cannot be underestimated as it may affect the recovery of anatomy and function.

The impact of macular surgery in different grades of epiretinal membrane

AIM：To assess the impact of macular surgery on the functional and anatomic outcomes of the patients in different grades of epiretinal membrane（ERM）.METHODS：Seventy-one eyes of 71 patients who underwent 23-gauge transconjunctival sutureless pars plana vitrectomy for primary isolated ERM were evaluated in this study.RESULTS：There were 38 females（53.5%） and 33 males（46.5%）.The average age of the patients was 68.1 y（range 42-89 y）.Mean follow up period was 14 mo（range 6-26 mo）.The cases were divided into two subgroups of cellophane maculopathy（CM） and macular pucker（MP）.An improvement was observed in the postoperative best-corrected visual acuity（BCVA）,as well as a decrement in central foveal thickness（CFT） in both groups（both of these being statistically significant;P=0.001）.In comparison between two groups,it was found that there was a significant improvement on BCVA and CFT in CM group than MP group（P=0.01）.Furthermore,the postoperative fundus findings regarding RPE alterations and macular edema were significantly higher in MP group when compared to the CM group（P=0.01）.CONCLUSION：ERM and internal limiting membrane peeling surgery can lead to a significant reduction of CFT and visual improvements in idiopathic ERM.A long-term ERM persistence will cause unrecoverable retinal damage and visual loss.

Comparison of anatomical and functional outcomes of different surgical techniques in myopic macular hole without retinal detachment

AIM:To define the anatomic and functional outcomes of pars plana vitrectomy(PPV)with internal limiting membrane(ILM)peeling,inverted ILM flap and free ILM patch graft technique for the treatment of myopic macular hole(MH)without retinal detachment.METHODS:Sixty-four eyes of 64 patients who underwent PPV for myopic MH were included.Group 1 consists of patients underwent ILM peeling(n=26),and Groups 2 and 3 consists of patient underwent free ILM patch graft(n=20)and inverted ILM flap procedure(n=18)respectively.Outcomes following surgery were MH closure and best corrected visual acuity(BCVA)in logMAR at 6mo.RESULTS:Closure of MH was obtained in 20 eyes(76.9%)of the Group 1,in 16 eyes(80%)of the Group 2 and in 16 eyes(88.9%)of the Group 3.The mean preoperative and postoperative BCVA was 1.60±0.53 logMAR and 1.27±0.58 logMAR,respectively(P<0.05).There was no significant difference in the postoperative BCVA and anatomical closure rates in the three groups.Although the anatomical closure rate did not differ significantly in the groups,closure of MH tended to be better in the inverted ILM flap technique group at 6mo.CONCLUSION:Different surgical techniques may provide favorable visual and anatomical results for myopic MH surgery.ILM flap techniques offer higher closure rates compared to ILM peeling technique.However,in terms of visual outcomes,the study reveals no difference in three surgical techniques.

Long-term follow-up of vitrectomy in patients with pathologic myopic foveoschisis

AIM： To report the long-term surgical outcomes of pathologic myopic foveoschisis（MF） following vitrectomy.METHODS： We performed a retrospective case series analysis of 50 consecutive patients diagnosed with MF who experienced vision loss due to progression of foveoschisis.The 50 patients（67 eyes） were treated in our hospital with vitrectomy with internal limiting membrane（ILM） peeling from December 2004 to September 2010.Best corrected visual acuity（BCVA）,refractive error,optical coherence tomography（OCT）,and routine examination results were analysed.The changes of BCVA,foveal anatomical features on OCT scan,and complications were the main outcome measures.RESULTS： The mean follow-up duration was 42±17mo（range 24 to 93mo）.BCVA improved significantly postoperatively（0.76±0.65 logM AR） compared with preoperative baselines（1.31±0.78 log MAR,P〈0.0001）,and in 53 eyes（79%） including 3 lines gain in 44 eyes（66%） at the last follow-up visit.OCT scans showed that central retinal thickness decreased from 580.0±270.0 μm preoperatively（n=67） to 179.7±84.7 μm postoperatively（n=58,P〈0.0001）.Total resolution of foveoschisis occurred in 41 eyes（61%）.Preoperative BCVA correlated well with postoperative BCVA,whereas other factors such as age,axial length,and refractive error were not correlated.The most common complications were cataract and full-thickness macular hole formation in 14 and 9 cases,respectively.CONCLUSION： Patients with progressive vision loss due to MF who were treated with vitrectomy with ILM peelingshow favourable outcomes.In most eyes,visual acuity and foveal structure remain stable during long-term observation.

New technique for removal of perfluorocarbon liquid related sticky silicone oil and literature review

AIM:To investigate the safety and efficacy of sticky silicone oil(SSO)removal using a 22-gauge vein detained needle and inner limiting membrane(ILM)wrap-and-peel technique.METHODS:This retrospective consecutive case series reviewed the records of patients with a history of retinal detachment who had received silicone oil and perfluorocarbon liquid(PFCL)as intraocular tamponades.Patients were included in the analysis if they exhibited SSO remnants during silicone oil removal.The aspiration of most of the SSO remnants was performed by a 22-gauge vein detained needle.The small amounts of droplets adhered to the macula and epi-macular membrane were subsequently removed by the ILM warp-and-peel technique.The anatomical and functional outcomes,and postoperative complications were recorded.In vitro experiments were performed to simulate the formation of SSO remnants in four groups.RESULTS:Of 711 patients who underwent silicone oil removal during the study period,9 patients exhibited SSO remnants and underwent follow-up for at least 3mo.Seven eyes(78%)underwent the ILM wrap-and-peel technique to completely remove small droplets of SSO that were glued to the macula and epi-macular membrane.No obvious complications occurred.Postoperative optical coherence tomography revealed normal retinal structure in all patients.In vitro analyses showed that balanced salt solution and prolonged vibration(for 1wk)had the strongest effects on silicone oil and PFCL compound opacities.CONCLUSION:SSO remnants could be removed in an intact manner and without complications,using a vein detained needle-assisted and ILM wrap-and-peel technique.The findings suggest that PFCL and infusion fluid should be completely removed before silicone oil injection to prevent SSO formation.