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1.  Internal limiting membrane removal in macular hole surgery for severely myopic eyes: a case-control study 
Aims: To determine the surgical outcome of indocyanine green (ICG) assisted retinal internal limiting membrane (ILM) peeling in macular hole surgery for severely myopic eyes and compare the visual and anatomical outcomes with an emmetropic control group.
Methods: 10 severely myopic eyes (−6.0 D or greater) of 10 patients with macular holes without retinal detachment were recruited prospectively. All eyes received ICG assisted ILM removal of 3–4 disc diameters around the macular holes. Cases were matched with a prospective control group of 10 emmetropic macular hole patients who underwent identical ICG assisted ILM peeling surgery in the same period.
Results: The mean refractive error in the myopic and control group was −11.8 D and +0.3 D, respectively (two tailed t test, p < 0.001). The mean follow up duration for the myopic and control group was 12.1 and 13.3 months, respectively (two tailed t test, p = 0.63). The primary anatomical closure rate in both groups was 90% (Fisher’s exact test, p = 1.0). For both the myopic and control groups, there were significant improvement in the mean log MAR visual acuity after the surgery with improvements from 0.86 to 0.57 for the myopic group (two tailed t test, p = 0.015) and 0.89 to 0.44 for the control group (two tailed t test, p = 0.002). The mean preoperative and postoperative visual acuity, rates of final visual acuity of 20/50 or better, and improvement of two or more lines were not statistically different between the two groups.
Conclusion: ICG assisted ILM peeling in macular hole surgery for severely myopic eyes without retinal detachment gives promising anatomical and visual outcomes, which are comparable to that of non-severely myopic eyes.
PMCID: PMC1771733  PMID: 12812892
severe myopia; indocyanine green; internal limiting membrane; macular hole
2.  A comparison of outcomes after indocyanine green and trypan blue assisted internal limiting membrane peeling during macular hole surgery 
Aims: To compare the anatomical and visual outcomes of macular hole repair surgery using indocyanine green (ICG) or trypan blue (TB) staining of the internal limiting membrane (ILM).
Method: Retrospective analysis of 37 eyes from 37 consecutive patients with stage 2, 3, and 4 idiopathic macular holes who underwent macular hole repair by one surgeon using the same technique but utilising different dyes for ILM peeling. In 19 patients ICG was used while 18 patients had TB. The anatomical and visual results in these two groups were compared.
Results: There were no significant differences in the demographic and macular hole characteristics of the ICG and TB groups. Macular hole closure was achieved in 91.9% of all patients of which the ICG group had an 89.5% hole closure rate and the TB group had a 94.4% hole closure rate. After excluding cases with failed hole closure and other vision affecting complications, there was no significant difference between the preoperative visual acuities in the TB and ICG groups but the postoperative visual acuities were better in the TB than the ICG group (p = 0.036). The TB group also had more Snellen lines of improvement than the ICG group (2.94 v 1.79 lines; p = 0.046).
Conclusion: TB appears to be less toxic than ICG when used in dye assisted peeling of ILM during macular hole repair as reflected by the better visual results in the TB group of patients.
PMCID: PMC1772609  PMID: 15774917
macular hole; indocyanine green; trypan blue
3.  Residual indocyanine green fluorescence pattern after vitrectomy for idiopathic macular hole with internal limiting membrane peeling 
Internal limiting membrane (ILM) peeling with indocyanine green (ICG) staining is a commonly used procedure to treat idiopathic macular holes (MH).
To report changes in the patterns of residual ICG fluorescence over time after vitrectomy using the Heidelberg Retina Angiograph 2 (HRA2, Heidelberg Engineering, Heidelberg, Germany).
10 patients (10 eyes) who had undergone vitrectomy for MH with ILM peeling were included. 9 (90%) patients underwent ILM peeling with ICG, and 1 (10%) patient had it with triamcinolone acetonide (TA). We observed residual ICG using HRA2, postoperatively. Autofluorescence, optical coherence tomography images and best‐corrected visual acuity (BCVA) measurements were also obtained. The minimal follow‐up was 3 months.
The MHs were closed postoperatively in all patients (100%). In eyes that underwent ILM peeling with ICG, the BCVA improved significantly (p<0.001) in 8 (89%) eyes and was unchanged in 1 (11%) eye. HRA2 showed the ICG fluorescence patterns but not TA postoperatively. The ICG hyperfluorescent signal was typically diffuse at the posterior retina and was hypofluorescent around the fovea. The hyperfluorescence then migrated towards the optic nerve disc presumably along the nerve fibre, and the area of ILM peeling was clearly identified. A large number of hyperfluorescent dots were observed instead of diffuse hyperfluorescence that was observed just after surgery.
Patterns of residual ICG fluorescence were sequentially observed with HRA2 after vitrectomy for MH with ICG‐assisted ILM peeling.
PMCID: PMC1955671  PMID: 17215268
4.  Indocyanine green assisted retinal internal limiting membrane removal in stage 3 or 4 macular hole surgery 
Aims: To determine surgical outcome in primary idiopathic stage 3 or 4 macular holes with indocyanine green (ICG) assisted retinal internal limiting membrane (ILM) peeling.
Methods: A prospective, consecutive, interventional case series with 41 eyes of 40 patients was included. No patient defaulted follow up. Besides a standard macular hole surgery, all eyes received ICG assisted ILM removal of 3–4 disc diameters around macular holes. At the end of the surgery, 12% perfluoropropane gas was used. A face down posture for 2 weeks was required postoperatively.
Results: The mean follow up period was 15.1 months (range 6–24 months). Twenty (48.8%) eyes had stage 3 macular holes and 21 (51.2%) had stage 4 macular holes. The overall median duration of holes was 11 months. 19 (46.3%) were chronic macular holes of more than 12 months’ duration. The anatomical success rates after one surgery was 87.8% (36 eyes), while that of chronic and non-chronic ones was 78.9% and 95.5%, respectively. The median preoperative and postoperative visual acuity was 20/200 (range 20/60 to counting fingers) and 20/100 (range 20/20 to 20/400), respectively. 24 (58.5%) eyes had improvement of two or more Snellen lines. The mean was 3.2 lines (range two to nine lines), with 3.6 lines and 2.7 lines for non-chronic and chronic holes, respectively. For all the 41 eyes, 16 (39%) eyes had a final visual acuity of 20/50 or better.
Conclusion: ICG assisted retinal ILM removal, in idiopathic primary chronic and non-chronic stage 3 or 4 macular hole surgery, appears to give a promising anatomical closure rate without compromising the visual result.
PMCID: PMC1771454  PMID: 12488266
indocyanine green; internal limiting membrane; macular hole
To compare the anatomic and functional results of 3 different epimacular dissection techniques on macular hole surgery.
Vitrectomy was performed in 123 eyes for macular hole in a retrospective, consecutive case series by one surgeon. The surgical technique was identical except for the method of epimacular dissection, which was performed using 1 of 3 techniques sequentially. The first group of 29 eyes had abrasion of the macula with a sharp pick (epiretinal dissection [ERD]), the second group of 32 eyes had partial or complete removal of the internal limiting membrane (ILM), without ILM staining. The third group of 62 eyes had complete removal of the ILM using indocyanine green (ICG) to stain the ILM.
The mean preoperative visual acuity was 20/125 -2 in the ERD and ILM groups and 20/160 -2 in the ICG groups (P = .167). Long-term successful closure of the macular hole was achieved with one operation in 22 of 29 ERD eyes (75.9%), 31 of 32 ILM eyes (96.7%), and 62 of 62 ICG eyes (100%). The mean visual acuity at 3 months was 20/63 +2 (ERD), 20/80 (ILM), and 20/125 (ICG) (P < .001), with significantly poorer visual acuity in the ICG group. The final visual acuity (mean, 2.27 years) was 20/63 +1 (ERD), 20/50 -2 (ILM), and 20/80 -1 (ICG, P = .073), with no significant differences in mean visual acuity, visual acuity gain, gain of ≥3 lines, or percentage ≥20/40.
Removal of the ILM decreases persistent and recurrent macular holes. ICG staining and complete removal of the ILM slows the rate of visual recovery but does not appear to have any long-term deleterious effect on the results of macular hole surgery.
PMCID: PMC2258112  PMID: 18427610
6.  Brilliant blue G-assisted peeling of the internal limiting membrane in macular hole surgery 
Indian Journal of Ophthalmology  2011;59(2):158-160.
Dye-assisted internal limiting membrane (ILM) peeling and gas tamponade is the surgery of choice for idiopathic macular holes. Indocyanine green and trypan blue have been extensively used to stain the ILM. However, the retinal toxicity of indocyanine green and non-uniform staining with trypan blue has necessitated development of newer vital dyes. Brilliant blue G has recently been introduced as one such dye with adequate ILM staining and no reported retinal toxicity. We performed a 23-gauge pars plana vitrectomy with brilliant blue G-assisted ILM peeling in six patients with idiopathic macular holes, to assess the staining characteristics and short-term adverse effects of this dye. Adequate staining assisted in the complete removal of ILM and closure of macular holes in all cases. There was no evidence of intraoperative or postoperative dye-related toxicity. Brilliant blue G appears to be safe dye for ILM staining in macular hole surgery.
PMCID: PMC3116549  PMID: 21350290
Brilliant blue G; macular hole; internal limiting membrane; peeling
7.  Clinical Outcomes of Double Staining and Additional ILM Peeling during ERM Surgery 
To assess the clinical outcomes in idiopathic epiretinal membrane (ERM) patients after vitrectomy and ERM removal with or without additional indocyanine green (ICG)-assisted internal limiting membrane (ILM) peeling.
The medical records of 43 patients with an idiopathic ERM that underwent vitrectomy and ERM removal between July 2007 and April 2010 were reviewed. The patients were divided into two groups: triamcinolone-assisted simple ERM peeling only (group A, n = 23) and triamcinolone-assisted ERM peeling followed by ICG staining and peeling of the remaining internal ILM (group B, n = 20).
No difference was found between the two groups in terms of visual acuity, macular thickness, P1 amplitude or implicit time on multifocal-electroretinogram (mfERG) at six and 12 months postoperatively. In group B, ICG staining after ERM peeling demonstrated that the ILM had been removed together with the ERM in 12 eyes (60%), and all 12 eyes showed punctate retinal hemorrhages during ERM peeling. There was no recurrence of an ERM in either group.
Additional procedures involving ICG staining and ILM peeling during ERM surgery do not appear to have an additive effect on the clinical outcomes in terms of visual acuity, retinal function based on mfERG, or recurrence rate.
PMCID: PMC3730067  PMID: 23908571
Double staining; Epiretinal membrane; Internal limiting membrane
8.  Virtual retinectomy: indocyanine green-assisted internal limiting membrane peeling as a surgical adjunct in repair of recurrent rhegmatogenous retinal detachment due to PVR 
The purpose of this study was to describe and evaluate a surgical approach, known as internal limiting membrane (ILM) peeling, as an adjunct to repair of recurrent retinal detachment due to proliferative vitreoretinopathy (PVR).
This was a retrospective case series. All eyes underwent repair of recurrent PVR-related rhegmatogenous retinal detachment incorporating macular indocyanine green-assisted ILM peeling. Patients with primary detachments, diabetes, staphyloma, or macular holes were excluded. The main outcome measure was the anatomic success of single surgery. The characteristics of the group were studied, including the number and types of previous detachment repair attempts, as well as the subsequent surgeries.
Fourteen eyes from 14 patients were included. Anatomic success with single surgery was achieved in 11 of 14 (79%) of the operated eyes using this technique, and eventual success was achieved in all eyes (100%). Among the failed repairs prior to ILM peeling, 8/14 eyes had scleral buckles, 7/14 had silicone oil tamponade, and two had inferior retinectomies. There was no subsequent development of epiretinal membranes after ILM peeling.
ILM peeling in conjunction with vitrectomy and peeling of peripheral membranes is an effective technique with a high anatomic success rate in the challenging scenario of PVR-related recurrent detachments. We describe the technique as an alternative to the traditional retinectomy.
PMCID: PMC3346193  PMID: 22570543
internal limiting membrane; retinal detachment; proliferative vitreoretinopathy; retinectomy; surgical technique
9.  The Expansion of RPE Atrophy after the Inverted ILM Flap Technique for a Chronic Large Macular Hole 
Case Reports in Ophthalmology  2014;5(1):83-86.
To report a case of the expansion of submacular retinal pigment epithelium (RPE) atrophy after using the inverted internal limiting membrane (ILM) flap technique for a persisting, large, stage IV macular hole (MH).
Case Report
A 79-year-old woman presented with a chronic large MH that remained open despite pars plana vitrectomy (PPV). The surgery was performed twice for the MH closure 14 years earlier. ILM peeling was not performed during the previous surgeries. The best-corrected visual acuity (BCVA) with the Landolt ring chart was 0.08 at her visit. The minimum MH diameter was 1,240 μm. Inverted ILM flap technique with 20% SF6 gas tamponade was performed for the MH closure. For the inverted ILM flap technique, 25-gauge PPV and ILM staining with indocyanine green were used. The ILM was peeled off for 2 disc diameters around the MH, but the ILM was not removed completely. The ILM was then inverted and covered the MH.
One month after surgery, the MH was closed, accompanied by glial cell proliferation spreading from the inverted ILM flap (as reported before). On the other hand, the area of the submacular RPE atrophy, which was already observed 1 week after surgery, gradually increased in size. BCVA improved to 0.3 six months after the surgery.
The inverted ILM flap technique may be promising even for persisting large MH which were not closed in previous surgeries, but long-term observation is needed because the detailed behavior of the inverted ILM and the Müller cells after surgery is not yet known.
PMCID: PMC3975172
Macular hole; Inverted internal limiting membrane flap technique; Chronic macular hole; Indocyanine green; Retinal pigment epithelium atrophy
10.  Reduction of thickness of ganglion cell complex after internal limiting membrane peeling during vitrectomy for idiopathic macular hole 
Eye  2012;26(9):1173-1180.
The aim of this study is to report a reduction in the thickness of the ganglion cell complex (GCC) after vitrectomy with internal limiting membrane (ILM) peeling in eyes with idiopathic macular hole (MH).
Twenty-eight consecutive eyes with an idiopathic MH treated by vitrectomy with ILM peeling were studied. All eyes had an intravitreal injection of indocyanine green to make the ILM more visible. The best-corrected visual acuity (BCVA), GCC thickness measured by spectral domain optical coherence tomography, and retinal sensitivity measured by microperimetry were determined before and at 3 and 6 months after the vitrectomy.
The MH in all eyes was closed after the initial surgery. The BCVA was significantly improved at 3 and 6 months (P<0.001 and P<0.001, respectively). The thickness of the GCC was significantly reduced at 3 and 6 months postoperatively (P<0.001 and P<0.001, respectively). The GCC thickness was significantly correlated with the retinal sensitivity in the central 10 degrees at 6 months (r=0.55, P=0.004).
A reduction of the GCC thickness was observed after vitrectomy with ILM peeling for idiopathic MH.
PMCID: PMC3443841  PMID: 22899004
ganglion cell complex; indocyanine green; internal limiting membrane; macular hole
11.  Relationship between macular hole size and the potential benefit of internal limiting membrane peeling 
The British Journal of Ophthalmology  2006;90(10):1239-1241.
To investigate the relationship between the size of macular holes and the possible benefit of internal limiting membrane (ILM) peeling.
84 consecutive cases of idiopathic macular hole followed up for at least 3 months were included in this retrospective study. Surgery comprised pars plana vitrectomy, peeling of any epiretinal membrane, 17% C2F6 (hexafluoroethane) gas filling and 10 days of positioning. 36 eyes had ILM peeling. The main outcome measure was the macular hole closure rate checked by optical coherence tomography.
The overall postoperative closure rate was 90.5%. For macular holes ⩾400 μm in diameter, the rate was 100% with ILM peeling versus 73.3% without (p = 0.015). For smaller macular holes, the rates were 100% in both groups. Postoperative gain in visual acuity was not significantly different in eyes with ILM peeling and those without.
ILM peeling does not seem to be useful for macular hole <400 μm in diameter. Its likely benefit has to be investigated for larger macular hole sizes, for which the failure rate is higher.
PMCID: PMC1857449  PMID: 16809385
12.  Clinical and cost-effectiveness of internal limiting membrane peeling for patients with idiopathic full thickness macular hole. Protocol for a Randomised Controlled Trial: FILMS (Full-thickness macular hole and Internal Limiting Membrane peeling Study) 
Trials  2008;9:61.
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.
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.
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 identifier NCT00286507.
PMCID: PMC2607251  PMID: 18980675
13.  Macular configuration determined by optical coherence tomography after idiopathic macular hole surgery with or without internal limiting membrane peeling 
The British Journal of Ophthalmology  2002;86(11):1240-1242.
Aims: To evaluate the effect of pars plana vitrectomy (PPV) with or without internal limiting membrane (ILM) peeling on the closure and configuration of idiopathic macular holes (IMH).
Methods: PPV was performed for IMH on 44 eyes with ILM peeling (ILM peeled group) and on 42 eyes without ILM removal (ILM preserved group). Optical coherence tomography (OCT) was performed on 34 ILM peeled eyes and 14 ILM preserved eyes after successful surgery. The repaired macular holes were classified by the OCT images as being of “good shape” (nearly normal foveal contour) or “poor shape” (abnormal foveal contour with flat fovea and steep edge, or with a thick retina without a foveal pit).
Results: The anatomical closure rate was significantly higher in the ILM peeled group (93.2%) than in the ILM preserved group (76.2%) (p = 0.028). In the ILM peeled group, 31 eyes had a fovea of good shape and three eyes had a fovea with a poor shape, while in the ILM preserved group, six eyes had a fovea of good shape and eight eyes had a fovea of poor shape. The percentage of eyes with good macular configuration in the ILM peeled group was significantly higher than in the ILM preserved group (p = 0.0003). No significant difference was found in the postoperative visual acuity and the increase of visual acuity between the ILM peeled group and the ILM preserved group (p = 0.26, and p = 0.91 respectively). There was also no significant difference in the postoperative visual acuity and improvement in visual acuity between eyes with a fovea of good shape and those with fovea of poor shape fovea (p = 0.99 and p = 0.66, respectively).
Conclusions: ILM peeling may provide better anatomical success and recovery of the macular shape, but the postoperative visual acuity and improvement of visual acuity were not related to the morphological results.
PMCID: PMC1771338  PMID: 12386079
optical coherence tomography; macular hole surgery; internal limiting membrane
14.  Outcomes of 23-gauge pars plana vitrectomy and internal limiting membrane peeling with brilliant blue in macular hole 
The evaluation of anatomic and visual outcomes in macular hole cases treated with internal limiting membrane (ILM) peeling, brilliant blue (BB), and 23-gauge pars plana vitrectomy (PPV).
Materials and methods:
Fifty eyes of 48 patients who presented between July 2007 and December 2009 with the diagnosis of stage 2, 3, or 4 macular holes according to Gass Classification who had undergone PPV and ILM peeling were included in this study. Pre- and postoperative macular examinations were assessed with spectral-domain optical coherence tomography. 23 G sutureless PPV and ILM peeling with BB was performed on all patients.
The mean age of patients was 63.34 ± 9.6 years. Stage 2 macular hole was determined in 17 eyes (34%), stage 3 in 24 eyes (48%), and stage 4 in 9 eyes (18%). The mean follow-up time was 13.6 ± 1.09 months. Anatomic closure was detected in 46/50 eyes (92%), whereas, in four cases, macular hole persisted and a second operation was not required due to subretinal fluid drainage. At follow-up after 2 months, persistant macular hole was detected in one case and it was closed with reoperation. At 12 months, an increase in visual acuity in 41 eyes was observed, while it remained at the same level in six eyes. In three eyes visual acuity decreased. There was a postoperative statistically significant increase in visual acuity in stage 2 and 3 cases (P < 0.05), however, no increase in visual acuity in stage 4 cases was observed.
PPV and ILM peeling in stage 2, 3, and 4 macular hole cases provide successful anatomic outcomes, however, in delayed cases, due to photoreceptor loss, it has no effect on functional recovery. BB, used for clarity of ILM, may be beneficial due to its low retinal toxicity.
PMCID: PMC3162299  PMID: 21887101
macular hole; internal limiting membrane; ILM peeling; brilliant blue
15.  Factors predicting outcome of vitrectomy for diabetic macular oedema: results of a prospective study 
To determine preoperative demographic, clinical, and optical coherence tomography (OCT) factors which might predict the visual and anatomical outcome at 1 year in patients undergoing vitrectomy and inner limiting membrane peel for diabetic macular oedema (DMO).
A prospective, interventional case series of 33 patients who completed 1 year follow up. Measurements were taken preoperatively and at 1 year. Outcome measures were logMAR visual acuity (VA) and OCT macular thickness. A priori explanatory variables included baseline presence of clinical and/or OCT signs suggesting macular traction, grade of diabetic maculopathy, posterior vitreous detachment, fluorescein leakage and ischaemia on angiography, presence of subretinal fluid, and peroperative indocyanine green (ICG) use.
33 patients completed 1 year follow up. On average VA deteriorated by 0.035 logMAR (p = 0.40). Macular thickness significantly improved by a mean of 139 μm (95% CI; 211 to 67, p<0.001). Patients with evidence of clinical and/or OCT macular traction significantly improved logMAR acuity (logMAR improvement  = 0.08) compared with patients without traction (logMAR deterioration 0.11, p = 0.01). Presence of subretinal fluid significantly predicted worse postoperative result (p = 0.01)
On average, patients showed a statistically significant improvement in central macular thickness following treatment but a marginal acuity worsening. Presence of subretinal fluid on OCT is hypothesised to be exudative rather than tractional in nature. The visual benefit of vitrectomy for DMO in this study was limited to patients who exhibit signs of macular traction either clinically and/or on OCT.
PMCID: PMC1856901  PMID: 16361663
diabetic macular oedema; vitrectomy; diabetic retinopathy; maculopathy; optical coherence tomography
16.  Non-Foveal Macular Holes After PPV for Macular Pucker 
To describe six patients (six eyes) who developed an eccentric macular hole after surgery for idiopathic epimacular proliferation.
Materials and Methods:
Review of records from six patients who developed eccentric macular holes postoperatively following vitrectomy in 107 consecutive cases with peeling of the epimacular proliferation and internal limiting membrane (ILM) from June 2004 to January 2009
Eccentric macular holes were developed from nine days to eight months (mean, 3.1 months) after epimacular proliferation peeling. The ILM was peeled in addition to the epimacular proliferation in five of the six cases. Of the six eccentric macular holes, four were located temporal to the fovea, one was located superior to the fovea, and one was located nasal to the fovea. Final visual acuities after a mean follow-up period of 17.3 months were 20/20 in two eyes, 20/25 in one eye, 20/40 in two eyes, and 5/200 in one eye. The eye with the eccentric macular hole nasal to the fovea had the poorest final visual acuity of 5/200.
Eccentric macular holes occurring after vitrectomy to remove epimacular proliferation is an uncommon postoperative finding. Various explanations have been suggested for the etiology of these holes, but there is no consensus. We suggested that the ILM tear should be initiated with a diamond dusted knife to reduce the likelihood of injury to the underlying Muller cells that may contribute to the formation of eccentric macular holes.
PMCID: PMC2934718  PMID: 20844682
Eccentric Macular Hole; Epimacular Proliferation; Epiretinal Membrane; Macular Pucker; Vitrectomy
17.  Residual triamcinolone acetonide at macular hole after vitreous surgery 
Indian Journal of Ophthalmology  2010;58(3):232-234.
Post traumatic macular holes have shown successful anatomic outcomes with vitrectomy with internal limiting membrane (ILM) peeling and gas injection. Intraocular use of triamcinolone acetonide (TA) crystals is gaining popularity in patients for visualization of the vitreous cortex, posterior vitreous detachment induction and ILM peeling during macular hole surgery. However, the possibility of residual steroid crystals clogging the hole at the conclusion of surgery exists. In our case, residual TA was observed biomicroscopically in the fovea on the seventh day after surgery, Optical Coherence Tomography (OCT) image of the eye showed a hyper reflective mass corresponding to the TA. However, a repeat OCT carried out four weeks after surgery showed recovery of the foveal morphologic features to an almost normal depression, with closure of the hole. Residual TA crystals in the macular hole post vitreous surgery may not interfere with ultimate macular hole closure or visual improvement.
PMCID: PMC2886256  PMID: 20413928
Internal limiting membrane peeling; macular hole; triamcinolone
18.  Progressive atrophy of retinal pigment epithelium after trypan-blue-assisted ILM peeling for macular hole surgery 
Indian Journal of Ophthalmology  2013;61(5):235-237.
We report a case of progressive atrophy of the retinal pigment epithelium (RPE) after trypan-blue-assisted peeling of internal limiting membrane (ILM) for macular hole surgery. A 68-year-old Caucasian female underwent a 20-g pars plana vitrectomy for a chronic stage-3 macular hole. The ILM was stained with 0.06% trypan blue (VisionBlue™, DORC Netherlands) for 2 min after fluid air exchange. Dye was reapplied for another 2 min due to poor staining. The ILM was completely removed around the macular hole with forceps. RPE atrophy was noticed at the edge of the hole 1 month after surgery. It progressively increased in intensity and enlarged over 2 years. Her final visual acuity was counting fingers, significantly worse compared to her presenting visual acuity of 20/200. Progressive atrophy of RPE in our patient was most likely due to the toxicity of trypan blue. Reapplication of the dye may increase the likelihood of toxicity.
PMCID: PMC3730510  PMID: 23619488
Internal limiting membrane; macular hole; retinal pigment epithelial atrophy; trypan blue; vital dyes
19.  Re-operation of idiopathic full-thickness macular holes after initial surgery with internal limiting membrane peel 
The British Journal of Ophthalmology  2011;95(11):1564-1567.
A retrospective consecutive case series to evaluate the efficacy of re-operation in patients with persistent or recurrent idiopathic full-thickness macular hole after initial surgery with internal limiting membrane peel (ILM).
491 patients underwent surgery for full-thickness macular hole from January 2004 to November 2007. Fifty-five patients either did not close or reopened during the follow-up period. Thirty patients with initial ILM peel underwent repeat surgery involving vitrectomy, enlargement of ILM rhexis and gas tamponade.
Anatomical closure rate was 88.8% for primary surgery and 46.7% (14/30) for re-operation. There was a statistically significant improvement in overall best corrected visual acuity (BCVA) from re-operation baseline BCVA (p=0.02) within 1 year. For holes that did not close after the second surgery, visual acuity did not worsen.
Re-operation has a reduced success rate of anatomical closure. However, BCVA is statistically significantly improved from re-operation baseline, so even though we cannot return vision to pre-pathological baseline, re-operation can improve on this new baseline.
PMCID: PMC3199446  PMID: 21355018
Macular hole; re-operation; internal limiting membrane peeling; indocyanine green; vitrectomy; vitreous; macula; vision; treatment surgery; vitreous; macula; vision; treatment surgery
20.  Retinal pigment epithelial atrophy following indocyanine green dye- assisted surgery for serous macular detachment 
Indian Journal of Ophthalmology  2008;56(5):423-425.
To report subretinal migration of indocyanine green dye (ICG) and subsequent retinal pigment epithelial (RPE) atrophy during macular surgery for serous macular detachment. A 65-year-old woman presented with residual epiretinal membrane and serous detachment of the macula following vitreoretinal surgery for epiretinal membrane. She underwent resurgery with ICG- assisted internal limiting membrane peeling and intraocular tamponade. Intraoperatively a large area of subretinal ICG was seen with subsequent RPE mottling and atrophy of the macula in the area involved during follow-up. This case demonstrates that subretinal migration of ICG is possible and can be toxic to RPE.
PMCID: PMC2636149  PMID: 18711276
Indocyanine green; macular hole; retinal pigment epithelial atrophy; serous macular detachment
21.  Retreatment of full‐thickness macular hole: predictive value of optical coherence tomography 
The British Journal of Ophthalmology  2007;91(11):1445-1449.
To determine whether the efficacy of re‐operation for idiopathic full‐thickness macular hole (FTMH) remaining open after initial surgery with internal limiting membrane (ILM) peeling is correlated with macular hole configuration as determined by optical coherence tomography (OCT), macular hole size, macular hole duration before the first operation, or type of tamponade (gas or silicone oil).
A retrospective consecutive interventional case series of 28 patients (28 eyes) with a persisting macular hole after vitrectomy, ILM peel, and gas tamponade. 28 patients underwent repeat surgery involving vitrectomy and gas (n  =  15) or silicone oil tamponade (n  =  12) or no tamponade (n  =  1). Autologous platelet concentrate (n  =  22), autologous whole blood (n  =  1), or no adjuvant (n  =  5) was used. Preoperative OCT was undertaken in all eyes. The main outcome measures were anatomical closure and improvement of best‐corrected visual acuity (BCVA).
Anatomical closure was achieved in 19 of 28 eyes (68%). BCVA improved in 12 eyes, remained unchanged in nine, and worsened in seven. BCVA improved in 11 of 19 eyes with anatomical closure, and in one of eight eyes without closure. Anatomical closure and improvement of BCVA correlated with preoperative macular hole configuration on OCT, with higher rates of closure (18 of 20 eyes versus one of eight eyes, p = 0.001) and greater improvement of BCVA (p = 0.048) in eyes with a cuff of subretinal fluid at the break margin. Macular hole size, type of tamponade, macular hole duration before the first operation, or preoperative BCVA did not significantly correlate with visual or anatomical outcome.
Macular hole configuration seems to be a strong prognostic indicator of anatomical closure and may help identify those patients most likely to benefit from re‐operation.
PMCID: PMC2095445  PMID: 17475704
OCT; macular hole; retreatment
22.  Evaluation of secondary surgery to enlarge the peeling of the internal limiting membrane following the failed surgery of idiopathic macular holes 
The aim of the present study was to evaluate the clinical results of pars plana vitrectomy (PPV) combined with the surgical enlargement of internal limiting membrane (ILM) peeling in patients who had previously undergone failed idiopathic macular hole (IMH) surgery. In the study, 134 eyes from 130 IMH patients who had received PPV combined with ILM peeling surgery (2 disk diameters) were analyzed. Within this cohort, 14 eyes had IMHs that were not closed, of which 13 eyes underwent a second surgery involving enlargement of the ILM peeling. The extent of the ILM peeling was increased to the vascular arcades of the posterior fundus in the secondary surgery. Of the 13 eyes that underwent secondary surgery, five were in stage III and nine were in stage IV. The second surgery successfully achieved IMH closure in 61.5% (8/13) of the eyes. The IMH was completely closed following surgery and the logMAR vision increased from 0.98 to 0.84 (P=0.013) in the 8 successfully treated cases. The surgical enlargement of ILM peeling closed the IMHs and improved vision in the majority of patients. In addition, the procedures were safe. Therefore, the results of the present study indicate that enlargement of ILM peeling may be an effective therapy for patients who have previously undergone the failed surgical correction of an IMH.
PMCID: PMC3919896  PMID: 24520279
idiopathic macular holes; internal limiting membrane peeling enlargement surgery; pars plana vitrectomy
23.  Pilot randomised controlled trial of face-down posturing following phacovitrectomy for macular hole 
Eye  2011;26(2):267-271.
To gather information on the effect of postoperative face-down posturing following combined phacoemulsification and vitrectomy for macular hole surgery in order to assist in the design of a larger definitive study.
Thirty phakic patients with stage II–IV full-thickness macular hole had combined phacoemulsification and pars plana vitrectomy with internal limiting membrane peel and 14% perfluoropropane (C3F8) gas. At the conclusion of surgery, patients were randomised either to face-down posture or to no posture, for 10 days. The primary outcome was macular hole closure.
The macular hole was successfully closed in 93.8% of the face-down posture group and in all of the no-posture group. Mean visual improvement was 0.63 (SD=0.21) logMAR units in the face-down group and 0.53 (SD=0.22) in the no posture patients.
Following combined phacoemulsification and vitrectomy, postoperative face-down posturing appears to make little difference to the final anatomical or visual outcome. If we assume a success rate of 95% in the posturing arm, and that there is no difference between posturing and non-posturing, then 798 patients would be required to be 90% sure that the 95% confidence interval will exclude a difference of more than 5%.
PMCID: PMC3272182  PMID: 21941363
macular hole; vitrectomy; posturing; phacoemulsification
24.  Indocyanine green-assisted epiretinal membrane peeling evaluated by optical coherence tomography and multifocal electroretinography 
To evaluate the anatomical and functional outcome in eyes with indocyanine green (ICG)-assisted idiopathic epiretinal membrane (ERM) peeling by optical coherence tomography (OCT) and multifocal electroretinogram (MFERG).
Prospective, interventional, noncomparative case series.
Twenty eyes of 20 patients with idiopathic ERM underwent pars plana vitrectomy and ICG-assisted ERM and internal limiting membrane (ILM) removal. Visual acuity (VA), OCT, and MFERG measurements were performed preoperatively and postoperatively at 1, 3, 6, and 12 months.
Best-corrected VA (BCVA) improved ≥2 Snellen lines in 70% of our patients at the 12th postoperative month. Mean VA increased from 20/100 preoperatively to 20/40 at 12 months. VA increased significantly at all postoperative examinations, compared to preoperative VA. Foveal thickness measured by OCT decreased significantly at all postoperative examinations. OCT mean values dropped from 472.3 μm preoperatively, to 249.2 μm at 12 months. Preoperative MFERG values significantly improved only at 12 months. OCT measurements and MFERG values did not correlate at any time. OCT values correlated with VA values only preoperatively while MFERG measurements correlated with VA at 12 months.
In our series of eyes with ERM surgery, OCT measurements and VA improved gradually throughout the first postoperative year, while MFERG values showed significant improvement at 12 months.
PMCID: PMC2704540  PMID: 19668533
25.  Treatment of idiopathic macular hole with silicone oil tamponade 
We analyzed the anatomical and visual outcomes after surgical treatment of idiopathic macular holes with pars plana vitrectomy, internal limiting membrane (ILM) peeling using Brilliant Blue dye, and silicone oil tamponade without postoperative posturing.
This was a retrospective interventional study of 10 eyes in eight patients who underwent surgical treatment of idiopathic macular holes using pars plana vitrectomy, ILM peeling using Brilliant Blue dye, and silicone oil tamponade without postoperative posturing. The preoperative staging of macular holes and postoperative anatomic outcomes were assessed using spectral-domain optical coherence tomography.
All patients were women with a mean age of 66.86 ± 4.8 years. In two patients, bilateral macular holes were present and both eyes were operated on. Stage 2 macular hole was diagnosed in three eyes, three eyes had stage 3, and four eyes had stage 4 macular holes. Anatomical success and closure of the macular hole was achieved in nine eyes (90%) after one operation. In one eye, the macular hole was closed after reoperation. The preoperative mean best-corrected visual acuity (BCVA) was 0.15 decimal units (0.8 logMAR units). Until the end of the follow-up period, BCVA was 0.25 decimal units (0.6 logMAR units). Visual acuity was improved in seven patients (70%). In two patients (20%), visual acuity remained at the same level, and in one eye (10%), visual acuity decreased. Postoperatively, all patients reported a significant reduction of metamorphopsia.
Initial results after 20G pars plana vitrectomy with peeling of the ILM, use of dye (Brilliant Blue), and tamponade with silicone oil without postoperative posturing gave good anatomical and functional outcome in terms of visual acuity and reduction of metamorphopsia. Taking into account the age of the patients, this method, which does not require prolonged postoperative face-down posturing, was well tolerated by the patients. Because the anatomical and visual outcome as well as the rate of postoperative complications are comparable to those when gas is used as a tamponading agent, silicone oil tamponade can also be safely used as a first option in surgery of macular holes. However, a longer period of follow-up of the operated eyes, as well as a larger group of operated eyes, will be required to identify long-term outcomes of this surgical treatment.
PMCID: PMC3460698  PMID: 23055662
macular hole; silicone oil; ILM peeling; pars plana vitrectomy

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