Complications of Macular Peeling

Comparison of Surgical Times Between Manual and Robot-Assisted Epiretinal Membrane Peeling

Purpose

Epiretinal membranes (ERM) pose a common challenge in vitreoretinal pathology, often causing vision impairment in older adults. The Preceyes Surgical System (PSS) supports the surgical removal of ERM through robot-assisted membrane peeling (RA-MP). This study compares surgical times and iatrogenic hemorrhages between manual membrane peeling (MMP) and RA-MP using PSS.

Methods

Nine patients underwent RA-MP with PSS, whereas 16 patients (18 eyes) underwent MMP for comparative analysis. Surgical durations were categorized into RA-MP, manual forceps utilization in PSS surgeries (mRA-MP), and traditional MMP. Cumulative manual manipulation duration (cMMP), instrument grasps, and intraoperative hemorrhages were statistically analyzed using the Mann-Whitney U test.

Results

RA-MP showed significantly longer peeling times compared to MMP (P < 0.001). Flap initiation grasps were similar between methods (P = 0.86), RA-MP demonstrated a significant reduction in peeling grasps (P = 0.01) and mean grasps per minute (P < 0.001). Although RA-MP resulted in fewer hemorrhages, the difference did not reach statistical significance relative to MMP (P = 0.08).

Discussion

Although RA-MP tended to extend surgical time, it offered advantages in reducing tissue trauma and intraoperative hemorrhages. Further research is needed to explore the learning curve for novice surgeons and evaluate the safety profile of RA-MP.

Translational Relevance

RA-MP may offer potential advantages over manual surgery, particularly in terms of reduced tissue trauma and intraoperative hemorrhages. Despite its longer duration compared with manual techniques, RA-MP may lead to fewer grasping maneuvers and lower rates of hemorrhages, thereby enhancing the safety and precision of vitreoretinal surgeries.

Analysis of retinal alterations utilizing intraoperative OCT following surgical interventions with novel ILM forceps in the DISCOVER study

This study aimed to assess retinal alterations following membrane peeling procedures using novel ILM Forceps with laser ablated surface with the help of intraoperative optical coherence tomography (iOCT). A post-hoc analysis was performed to evaluate iOCT findings in eyes that underwent membrane peeling procedures with the novel ILM Forceps. Pre-peel and post-peel iOCT videos and images were evaluated for each eye to assess for post-peel anatomic alterations. Surgical video/iOCT scan correlation was conducted to evaluate the etiology of anatomic alterations. Thirty-two eyes were included in the analysis. Three eyes (9%) had focal full thickness retinal elevations identified on iOCT following tissue-instrument interaction with the ILM Forceps. Two eyes (6%) had focal inner retinal elevations and one eye (3%) had a full-thickness retinal elevation that were not related to direct tissue-instrument interaction but rather indirect peeling forces. iOCT-identified architectural alterations related to direct-tissue instrument interaction were relatively infrequent (< 10%) with similar frequency to previously reported alterations with other surgical instruments.

Could internal limiting membrane peeling before Voretigen neparvovec-ryzl subretinal injection prevent focal chorioretinal atrophy?

Purpose

To report the effect of internal limiting membrane (ILM) peeling prior to Voretigen Neparvovec-ryzl (VN) subretinal injection on focal chorioretinal atrophy development in patients presenting with RPE65-mediated Leber congenital amaurosis (LCA).

Design

Retrospective case series.

Methods

Three patients who underwent bilateral subretinal VN injection for RPE65-mediated LCA were followed up for 18-24 months. ILM peeling was performed unilaterally in patients 1 and 2 and bilaterally in patient 3. Chorioretinal atrophy was identified on fundus biomicroscopy, non-mydriatic retinography and/or ultrawide field fundus imaging. Best corrected visual acuity (BCVA), spectral-domain optical coherence tomography (SD-OCT), visual fields, full-field stimulus threshold (FST) and visual functioning questionnaire score (NEI-VFQ-25) were reported. Outcome measures were changes in BCVA, visual fields, FST, NEI-VFQ-25, and chorioretinal atrophy location.

Results

Chorioretinal atrophy at the injection site exclusively developed in eyes which did not undergo prior ILM peeling. In patient 3, bilateral pre-operative nummular chorioretinal alterations progressed toward epithelial atrophic patches in the mid and extreme retinal periphery 18 months after VN injection. BCVA and visual fields improved bilaterally. NEI_VFQ 25 remained stable in patient 1 and improved in patient 2 and 3. FST test improved bilaterally in patient 3.

Conclusions

ILM peeling prior to VN injection seems to be a smoother and safer technique to administer VN treatment and may prevent secondary focal atrophy development at the injection site. However, another type of more extended chorioretinal atrophy might exist and could be related to LCA evolution or to incompletely understood adverse effect of VN product.

Development of an Eccentric Macular Hole Followed by Reopening of the Original Macular Hole as a Long-term Sequelae of Internal Limiting Membrane Peeling and Focal Laser Photocoagulation: A Case Report

A macular hole (MH) is a widely known disease among ophthalmologists. Vitrectomy with internal limiting membrane (ILM) peeling is a standard technique for full-thickness MHs. However, the recurrence of MHs is sometimes seen. In addition, an eccentric MH is known to rarely occur after vitrectomy. An eccentric MH has been considered to require no therapeutic intervention because of its lack of increase in size. This study reports a case of two MHs (a recurrent MH and an enlarged eccentric MH) developed after laser photocoagulation around the injured retina caused by ILM peeling at the initial surgery. A 56-year-old woman presented with an idiopathic MH in her left eye and best-corrected visual acuity (BCVA) was decreased to 20/80. She underwent phacoemulsification and vitrectomy combined with posterior hyaloid removal, ILM peeling, and 20% sulfur hexafluoride gas tamponade.  During the ILM peeling, we performed laser photocoagulation around the injured retina within the arcade. The MH was successfully closed and her BCVA was improved to 20/20 one month after surgery. Eight months after surgery, an eccentric MH occurred next to the photocoagulation spots. However, her BCVA remained 20/20; thus, we just followed up on her eye. Six years after surgery, her BCVA was decreased to 20/200. The eccentric MH increased in size and the original MH re-opened. The second vitrectomy was performed, but ILM had been already peeled within the arcade during the previous surgery and a usable sufficient size of ILM which could be auto-transplanted to the holes was not obtained. Thus, free flaps of the posterior lens capsule were harvested and placed within each hole. Two holes were successfully closed and her BCVA improved to 10/20 at three months after the surgery. Laser photocoagulation around the injured retina derived from ILM peeling may be a risk for recurrent MHs. .

Sudden branch macular artery avulsion during internal limiting membrane peeling for idiopathic macular hole: A case report

INTRODUCTION AND IMPORTANCE

Macular Holes (MH) are variable thickness openings of the retina that develop in the fovea. This case presents a branch macular artery avulsion during internal limiting membrane (ILM) peeling for idiopathic macular hole management in an adult patient. The proper management of this complication along with the preventive measures is mentioned.

CASE PRESENTATION

A 65-year-old woman developed a branch macular artery avulsion during ILM peeling for MH. After cataract extraction by phacoemulsification with intraocular lens implantation and pars plana vitrectomy, during ILM peeling, a multifocal bleeding along a macular artery was noted indicating its avulsion. The intraocular pressure was raised to control hemorrhage, blood remnants were passively aspirated and ILM peeling was kindly completed under adequate visualization.

CLINICAL DISCUSSION

Branch macular artery avulsion is a potential complication even for experienced surgeons. Proper management of this complication involves the increase of intraocular pressure for hemostasia. If hemostasia and proper visualization are achieved, the surgery could be completed, and if it is not the case, the ILM peeling could be completed in a second procedure. This complication might be avoided by initiating the ILM peeling away from the macular vessels.

CONCLUSION

Branch macular artery avulsion is an intraoperative complication that might be avoided by initiating the ILM peeling away from the macular vessels.

Assessment of Vascular Changes in Patients after Pars Plana Vitrectomy Surgery Due to Macula-Off Rhegmatogenous Retinal Detachment

The aim of this study was to investigate the changes in the retinal capillary plexuses in patients after pars plana vitrectomy (PPV), which is used for the treatment of rhegmatogenous retinal detachment (RRD). In this study, we included the results of 114 patients who underwent PPV after total retinal detachment (RRD; retinal detachment group). It should be kept in mind that to qualify for the study group, there was a condition that retinal detachment be only present in one eye, allowing the fellow healthy eye to be used for the control group, and the study, therefore, did not include cases where retinal detachment occurred binocularly. Optical coherence tomography (OCT) and OCT-A images were taken at 9 ± 2 months (median 10 months) after the surgery, with the study conducted in the years 2017–2019. OCT was used to examine the external limiting membrane (ELM), central macular thickness (CMT) and retinal nerve fiber layer (RNFL), while OCT-angiography (OCT-A) was used to examine the extent of the foveal avascular zone (FAZ) in the deep and superficial capillary plexuses. Changes in the FAZ area of the superficial plexus (SCP) between the study and control groups were analyzed over 346 ± 50 days. In our study, we observed changes in the FAZ area between the RRD and control groups in the SCP (203.65 ± 31.69 μm² vs. 215.30 ± 35.82 μm²; p = 0.28733) and DCP (284.79 ± 35.82 µm² vs. 336.84 ± 32.23 µm²; p = 0.00924). Changes in the RNFL thickness between the study and control groups over 346 ± 50 days were as follows: 90.15 μm vs. 82.44 μm; p = 0.19773. Disruption of the external limiting membrane was observed in 78.95% (90 eyes) of the study group. In the control group, it was undamaged, and no integrity disorder was observed. In the RRD, changes occurred in the FAZ of both the SCP and the DCP, which reduced the extent of this zone, an effect that was more pronounced in DCPs. A better understanding of the anatomical and hemodynamic changes taking place in the retina after macula-off RRD might be helpful in answering the question as to why BCVA in these cases is “only” or “as much as” from 0.4 to 0.1, namely, that it might be related to changes in the neurosensory retina after macular peeling.

Comparison of Anatomical and Functional Results of Surgeries Performed with Nitinol Flex Loop or Forceps in Primary Epiretinal Membrane

Purpose: To compare surgery's effect with nitinol flex loop (NFL) or forceps on retinal layers and functional outcomes in the primary epiretinal membrane (ERM).Methods: The operations were classified according to the use of the NFL or forceps. Automatic segmentation of the individual inner retinal layers was performed by spectral-domain optical coherence tomography software, and best-corrected visual acuity (BCVA) before surgery and at the last follow-up visit postoperatively were compared.Results: Forty-two eyes of 42 patients were included with a mean age of 66.9 ± 5.7 years. 45.2% of the surgeries were NFL assisted, 54.8% were forceps assisted. The mean follow-up duration was 9.8 ± 1.3 months. The mean BCVA was 0.79 ± 0.42 vs 0.77 ± 0.39 logMAR in the preoperative period and 0.42 ± 0.27 vs. 0.40 ± 0.21 logMAR at last follow-up in the NFL vs forceps group respectively (p= .403). The retinal nerve fiber layer (RNFL)(32.5% vs. 50.1%, p= .009), ganglion cell layer (18.1% vs. 41.4%, p= .021), inner plexiform layer (13.5% vs. 32.7%, p= .031) and inner nuclear layer (15.5% vs. 30.3%, p= .011) thickness decreased significantly more in the forceps group. The mean surgical time was not significantly different (45.2 ± 5.1 vs. 51.1 ± 6.1 minutes) in the NFL vs. forceps groups, respectively (p= .331).Conclusion: Following primary ERM surgery, the inner retinal layers become thinner; RNFL impacted the most, which was found higher in forceps assisted surgeries. This result shows that the NFL can be used safely in macular surgery.

Choroidal neovascularisation following inverted internal limiting membrane flap technique for idiopathic macular hole: a case for modified flaps

A 70-year-old woman presented with sudden decrease of vision 2 months following a successful vitrectomy with inverted internal limiting membrane flap for a full thickness macular hole. Serial review of fundus pictures and optical coherence tomography scans revealed a focal retinal pigment epithelial disruption at the site of the macular hole after surgery and a choroidal neovascular membrane arising from the same. This report describes the possible role of the surgical technique in causation of the membrane and discusses modifications to avoid the same.

Unintentional retinal artery amputation during macular peeling

Objective: To report a case of unintentional retina artery amputation during macular peeling.

Methods: Observational case report

Results: A 73-year-old female underwent surgery to treat epiretinal membrane (ERM) associated with severe staphyloma in her left eye. While the ERM/posterior hyaloid membrane visually enhanced with triamcinolone (TA) was peeled, a movement of the forceps unintentionally involved the inferior temporal branch artery near the inner edge of the staphyloma. The artery was avulsed and amputated. Oozing from the retinal cleft that had once enfolded the artery and microscopic bleeding from the amputation stump were observed. The vitreous hemorrhage obscured a view of the fundus more than 4 weeks after the surgery. After 8 weeks, postoperative visual acuity was improved; however, the superior nasal visual field was lost, and the patient was aware of the broken vessel as a floater in her vision.

Conclusions: Macular peeling is technically challenging, so meticulous attention must be paid to avoid any damage on vessels. The retina tissue was stretched in a staphyloma and vessels were bulged into the vitreous space especially at the inner edge of the staphyloma. High levels of TA dye here buried the texture of the retina. Excessive TA should be removed prior to macular peeling.

COMPARATIVE ANALYSIS OF RETINAL REATTACHMENT SURGERY WITH OR WITHOUT INTERNAL LIMITING MEMBRANE PEELING TO PREVENT POSTOPERATIVE MACULAR PUCKER

PURPOSE

To determine whether internal limiting membrane (ILM) peeling during pars plana vitrectomy for rhegmatogenous retinal detachment reduces the incidence of epiretinal membrane (ERM) formation.

METHODS

In this retrospective study, preoperative, intraoperative, and postoperative data from all eyes undergoing pars plana vitrectomy for rhegmatogenous retinal detachment between January 2007 and December 2013 was analyzed. All cases with at least 1-year of follow-up were included. Data collection included vision, intraoperative complications, occurrence of ERM, and spectral domain optical coherence tomography characteristics. The OCTs were retrieved for all eyes and were graded by a single masked grader.

RESULTS

Out of 159 eyes recruited, ILM peeling was done in 78 eyes (49%). Overall occurrence of ERM was 20%. Seven eyes (9%) in ILM peeling group and 25 eyes in the non-ILM peeling group (31%) showed ERM (P = 0.001). Postoperative vision was significantly better in eyes that had ILM peeling (0.48 ± 0.4 logarithm of the minimum angle of resolution [20/63] vs. 0.77 ± 0.6 logarithm of the minimum angle of resolution [20/125], P = 0.003). In multivariable models adjusting for type of tamponade, ILM peeling reduced the likelihood of ERM formation by 75% (P = 0.01).

CONCLUSION

Internal limiting membrane peeling during pars plana vitrectomy for rhegmatogenous retinal detachment significantly reduces ERM formation in the postoperative period and is associated with better visual and anatomical outcomes.

IATROGENIC CHOROIDAL NEOVASCULAR MEMBRANE IN MACULAR HOLE-INDUCED RETINAL DETACHMENT

PURPOSE

To report a case of choroidal neovascular membrane after vitreoretinal surgery in a patient with macular hole-induced retinal detachment.

METHODS

Retrospective observational case report.

CASE DESCRIPTION

A 64-year-old lady presented with sudden drop in vision in the right eye since 20 days. Her best-corrected visual acuity was 6/36 in the right eye and 6/18 in the left eye. She was diagnosed with retinal detachment with a macular hole in the right eye. She underwent vitrectomy with internal limiting membrane peeling and gas tamponade for the retinal detachment. Internal limiting membrane peeling was performed after staining with brilliant blue green dye and over the detached retina. Drainage of the subretinal fluid was performed through the macular hole and drainage retinotomy. Four months of postoperative examination revealed a scarred subfoveal choroidal neovascular membrane and retinal pigment epithelial atrophy surrounding it. This was confirmed by fluorescein angiography and optical coherence tomography.

CONCLUSION

Visual loss secondary to choroidal neovascular membrane can occur because of surgical trauma to the retinal pigment epithelium and Bruch membrane. Drainage of the subretinal fluid should be preferably avoided through the macular hole to prevent this complication.

Effects of internal limiting membrane peeling during vitrectomy for macula-off primary rhegmatogenous retinal detachment

PURPOSE:

To determine the effectiveness of internal limiting membrane peeling during vitrectomy for macula-off primary rhegmatogenous retinal detachment in the prevention of postoperative epiretinal membrane formation and achievement of good visual outcomes and to identify preoperative and intraoperative risk factors for epiretinal membrane formation.

METHODS:

We retrospectively analyzed data from 62 eyes of 62 consecutive patients with macula-off primary rhegmatogenous retinal detachment who underwent vitrectomy with (n = 30) or without (n = 32) internal limiting membrane peeling between January 2014 and March 2016 and were followed up for at least 12 months. The effects of internal limiting membrane peeling on visual outcomes and postoperative recovery of the macular structure were determined. We subsequently divided patients into an epiretinal membrane group and a non-epiretinal membrane group and assessed the effects of various preoperative and intraoperative factors on postoperative epiretinal membrane formation.

RESULTS:

Postoperative epiretinal membrane developed in 10 patients in the no internal limiting membrane peeling group and three patients in the internal limiting membrane peeling group. Postoperative visual acuity significantly improved in both groups. Epiretinal membrane formation was found to be correlated with a higher number of retinal breaks.

CONCLUSION:

Our results suggest that internal limiting membrane peeling during macula-off primary rhegmatogenous retinal detachment surgery can reduce the occurrence of postoperative epiretinal membrane, is safe, and results in favorable visual outcomes.

Differences in Surgical Performance of Internal Limiting Membrane Peeling for Macular Hole Repair Between Supervised Vitreoretinal Fellows and Vitreoretinal Faculty at a Single Institution

Purpose:

To investigate the differences in surgical maneuvers between vitreoretinal fellows and experienced vitreoretinal surgeons (attendings) when performing internal limiting membrane (ILM) peel during macular hole (MH) surgery and repair.

Methods:

Prospective case series. Macular hole surgeries performed by fellows and attendings at St Michael’s Hospital (Toronto, Canada) were recorded during a 12-month period. Evaluation of recordings was masked. Total peel time (TPL) in seconds, total movement attempts initiating and extending ILM flaps, intrasurgical complications, and surgical efficiency (ratio of approaches leading to case progression to total approaches) were quantified.

Results:

A total of 145 surgeries were evaluated; 44 met inclusion and exclusion criteria. Of the 44 cases, 25 were performed by fellows and 19 by attendings. Mean TPL was shorter for attendings (336 vs 506 seconds, P = .0032). Attendings had a lower average total movement attempts (32.2 vs 43.2, P = .045) and average flap initiation attempts (16.1 vs 23.3, P = .042). Surgical efficiency was better for attendings (45% vs 37% of approaches led to case progression, P = .038). There was no significant difference between groups in total flap extension attempts or intrasurgical complications.

Conclusions:

Compared to fellows, attendings peel ILM in MH surgery faster, more efficiently with a lower number of flap initiation attempts and total movements.

Analysis of Retinal Architectural Changes Using Intraoperative OCT Following Surgical Manipulations With Membrane Flex Loop in the DISCOVER Study

Purpose

We investigate acute retinal alterations identified on intraoperative optical coherence tomography (iOCT) immediately following surgical intervention with the Finesse Flex Loop for vitreoretinal interface disorders.

Methods

The Determination of feasibility of Intraoperative Spectral domain microscope Combined/integrated OCT Visualization during En face Retinal and ophthalmic surgery (DISCOVER) study is a prospective multisurgeon intraoperative OCT clinical study. Subjects who had participated in the DISCOVER study and had undergone macular surgery with the membrane flex loop from August 2014 to July 2016 were identified. iOCT images and video sequences were evaluated at various surgical time points. Subjects were excluded if iOCT images were not obtained over the area of membrane peeling performed with the membrane flex loop. Qualitative characteristics of intraoperative changes in retinal images were analyzed, with particular focus on the retinal layers within the bed of membrane peeling performed specifically with the membrane flex loop.

Results

We studied 34 eyes of 34 patients, with a mean age of 72.7 (± 6.4) years, 25 of whom were women. The intraoperative diagnosis was full thickness macular hole in 21 eyes (62%) and epiretinal membrane in 13 (38%). All eyes had successful indocyanine green–assisted inner limiting membrane (ILM) flap initiation using the membrane loop. Intraoperative OCT demonstrated expansion of the ellipsoid zone-to-RPE distance in 3 eyes (9%), definitive subretinal fluid accumulation in 1 eye (3%), and hyperreflectivity of the inner retinal layers associated with retinal hemorrhage in 10 eyes (29%). Retinal breaks were not observed in any eye.

Conclusions

Acute retinal alterations after ILM peeling with the membrane flex loop were visualized at a frequency of less than 10%. Additional research is needed to understand the clinical impact, if any, of these architectural alterations.

Epiretinal membrane negative staining and double peeling in a single block with Brilliant Blue G

Purpose:

To describe a surgical technique for combined peeling of epiretinal and internal limiting membranes.

Methods:

The authors present their procedure of choice for epiretinal membrane surgery: negative staining effect using Brilliant Blue G and single block removal of the epiretinal and internal limiting membranes in a single step.

Results:

A total of 26 eyes were operated with the described technique. In all cases, the peeling was performed successfully and with no complications. Minimum postoperative follow-up was 12 months. There were no recurrences of epiretinal membranes.

Conclusions:

The ideal surgical approach for epiretinal membranes should attempt to reduce mechanical trauma, light exposure, and dye toxicity.