Internal limiting membrane peeling is now widely used in the treatment of vitreoretinal diseases, such as idiopathic macular hole, epiretinal membrane, macular edema, traumatic retinopathy, retinoschisis, and optic pit, especially macular diseases. Due to the attention paid to the physiological function of the internal limiting membrane, there is still controversies about whether the internal limiting membrane is removed, and the area and the way of the removal in vitrectomy of the above diseases. Major complications have been reported in literature: effects on internal retinal structure, retinal and choroidal blood flow, retinal electrical activity, potential retinal toxicity of stain, changes in the anatomy of macular area, changes in visual field and potential damage to vision. In this paper, we reviewes the complications of internal limiting membrane peeling in the treatment of macular hole and epiretinal macular membrane.
ObjectiveTo observe the effect of internal limiting membrane peeling and transplantation on vision-related quality of life in refractory macular hole.MethodsA retrospective clinical study. Thirty patients (30 eyes) with refractory macular hole diagnosed in Ophthalmology Department of The First Affiliated Hospital of Nanjing Medical University from January to December 2016 were included in this study. There were 13 males (13 eyes) and 17 females (17 eyes), with the mean age of 57.3±6.9 years. There were 15 patients (15 eyes) with large macular diameter, 12 patients (12 eyes) with high myopia macular hole, and 3 patients (3 eyes) with secondary traumatic macular hole. The BCVA examination was performed using the Snellen visual acuity chart, which was converted into logMAR visual acuity. OCT was performed to measure the macular retinal thickness (CRT), base diameter and minimum diameter of macular hole. Then, the macular hole index (MHI) was calculated. The logMAR BCVA was 1.52±0.30, MHI was 0.51±0.19. The Chinese version of visual-related quality of life scale -25 (CVRQoL-25) was used to evaluate the vision-related quality of life of patients. The CVRQoL-25 score was 57.60±7.13. All patients underwent 23G vitrectomy combined with inner limited membrane peeling and autologous ILM transplantation. The follow-up was at least 3 months after surgery. The changes of BCVA, MHI, CRT and CVRQoL-25 score before and after surgery were comparatively analyzed. Paired t test was performed to compare the measurement data before and after surgery, and Spearman rank correlation analysis was used for the correlation analysis among the parameters.ResultsAt 3 months after surgery, the hole closure was detected in 28 eyes (93.3%), not detected in 2 eyes (6.7%). The logMAR BCVA was 1.16±0.33, CRT was 161.00±15.26, and CVRQoL-25 scores was 70.83±9.77. Compared with before surgery, the BCVA (t=4.386, P=0.000) and CVRQoL-25 score (t=-5.991, P=0.000) after surgery were improved. Spearman rank correlation analysis showed that CVRQoL-25 score was negatively correlated with preoperative and postoperative logMAR BCVA (r=−0.536, −0.796; P=0.002, 0.000); positively correlated with preoperative MHI (r=0.421, P=0.020) and postoperative CRT (r=0.589, P=0.001).ConclusionInternal limiting membrane peeling and transplantation for refractory macular hole can significantly improve the vision-related quality of life and visual acuity, while achieved a high hole closure rate (93.3%).
ObjectiveTo compare the efficacy of pars plana vitrectomy (PPV) combined inverted internal limiting membrane (ILM) with PPV combined ILM peeling for macular hole retinal detachment (MHRD) in high myopia.MethodsA retrospective clinical study. From October 2012 to January 2019, 78 patients (78 eyes) with high myopia macular hole retinal detachment diagnosed from Chongqing Aier Eye Hospital and Hefei Aier Eye Hospital were included in the study. Among them, there were 11 males (11 eyes) and 67 females (67 eyes) with the average age of 55.6±9.6 years. All patients underwent BCVA, diopter, OCT examination and axial length (AL) measurement. The standard logarithmic visual acuity chart was used for BCVA examination, and the visual acuity was converted to logMAR when recorded. Patients were divided into PPV combined with ILM peeling group (ILM peeling group) and PPV combined with ILM inverted group (ILM inverted group) according to the surgical method, with 51 patients (51 eyes) and 27 patients (27 eyes), respectively. The average age (t=－1.170), diopter (t=0.504), AL (t=0.474), logMAR BCVA (t=0.935), and hole diameter (t=－0.334) of the two groups were compared, and there was no statistically significant difference (P＞0.05). Two independent sample t test was used to compare the exposed distance of BCVA and RPE before and after the operation of the two groups of eyes. The χ2 test was used to compare the rates between the two groups.ResultsAt the last follow-up, the logMAR BCVA of the eyes in the ILM inverted group and ILM peeling group were 0.87±0.27 and 1.45±0.39, respectively. Compared with pre-operation, the BCVA of the two groups of eyes were significantly improved, and the difference was statistically significant (t=8.790, 4.640, P＜0.001,＜0.001). The logMAR BCVA of the two groups of eyes was compared with statistical significance (t=6.830, P＜0.001). The exposed RPE distances of the eyes in the ILM inverted group and the inner limiting membrane peeling group were 31.81±23.52 and 681.80±466.61 μm, respectively. the difference in the RPE exposure distance between the two groups was statistically significant (t=7.180, P＜0.001). The holes in the 27 eyes in the ILM inverted group were healed (100%, 27/27); no retinal detachment occurred. Among the 51 eyes in the ILM peeling group, the hole healed in 45 eyes (88.2%, 45/51), and the retina was detached in 6 eyes (11.8%, 6/51). There was a statistically significant difference in the incidence of retinal detachment between the two groups of patients (χ2=45.440, P=0.000).ConclusionCompared to ILM peeling, inverted ILM has provided better RPE protection and reduce the rate of retinal redetachment in patients with MHRD.
The main treatment methods of macular edema (ME) are intravitreal injection of anti-vacular endothelial growth factor drugs, corticosteroids, retinal laser photocoagulation and pars plana vitrectomy (PPV). However, recurrent ME, epiretinal membrane formation and drug resistance have occurred to a part of patients, which is called refractory ME (RME). PPV with internal limiting membrane peeling (ILMP) has the potential of treating and relieving RME. PPV combined with ILMP can treat and relieve RME by removing the posterior vitreous cortex, or removing the epiretinal membrane or internal limiting membrane at the same time during surgery to relieve the traction between the vitreous body and the retina. However, due to the complex pathogenesis of ME, the therapeutic effects of PPV combined with ILMP on ME caused by different etiologies still need clinical studies to explore the best surgical methods for ME caused by different etiologies.
ObjectiveTo observe the efficacy of pars plana vitrectomy (PPV) combined with internal limiting membrane (ILM) peeling and vitreous injection of mouse never growth factor (mNGF) in the high myopia macular hole (HMMH). MethodsA prospective study. Thirty-one patients (33 eyes) with HMMH diagnosed in Affiliated Eye Hospital of Nanchang University from August 2020 and February 2021 were selected. Before surgery, all included patients were subjected to a complete ophthalmologic evaluation including best corrected visual acuity (BCVA), optical coherence tomography (OCT), macular microperimetry and axial length measurement. The BCVA examination was carried out using the international standard visual acuity chart, which was converted into logarithm of minimum resolution angle (logMAR) visual acuity during statistics. The included subjects were accepted the treatment of PPV combined with ILM peeling and vitreous injection of mNGF (combined group) or PPV united with ILM peeling (simple group), 15 cases with 16 eyes, 16 cases with 17 eyes, respectively. There were no significant differences in logMAR BCVA (t=0.836), macular hole (MH) diameter (t=0.657), visual acuity (VA) (t=0.176), the missing length of external limting membrane (ELM) and ellipsoid zone (EZ) (t=1.255, 0.966) between two groups (P＞0.05). The follow-up time was at least 6 months. The BCVA, closure rate of MH, integrity of ELM and EZ and recovery of VA in macular area were compared and observed between the two groups after surgery. The logMAR BCVA, VA, the deficient lengths of ELM and EZ at different time points were compared by independent-samples t-test between two groups and analysis of variance was used to compare the repeated measurement data of each group. Fisher test was performed for comparison of count data. ResultsSix months after surgery, MH closure rates in the simple group and the combined group were 88.24% (15/17) and 93.75% (15/16), respectively, with no significant difference (P=0.523). At 3 and 6 months after surgery, the integrity recovery of ELM in the combined group was better than that in the simple group, and the difference was statistically significant (t=2.282, 3.101; P＜0.05). At 1, 3 and 6 months after surgery, EZ deletion length in the combined group was lower than that in the simple group, and the difference was statistically significant (t=1.815, 2.302, 2.784; P＜0.05). Compared with 1 week after surgery, VA in macular area of the combined group increased at 1, 3 and 6 months, and the difference was statistically significant (P=0.007, ＜0.001, ＜0.001). At 3 and 6 months after surgery, VA in macular area of affected eyes in the combined group was higher than that in the simple group, and the difference was statistically significant (t=1.897, 2.250; P＜0.05). There was an interaction effect between the surgical method and the follow-up time. The postoperative time was prolonged, and the VA in macular area was decreased in the simple group and increased in the combined group, with statistical significance (F=12.963, P＜0.001). The BCVA and BCVA changes in the two groups increased with the extension of postoperative time. The improvement of BCVA and the difference of BCVA changes in the combined group were significantly higher than those in the simple group at different time points after surgery, with statistically significant differences (F=12.374, 21.807, 5.695, 4.095; P＜0.05). ConclusionPPV combined with ILM peeling and vitreous injection of mNGF is more effective than PPV with ILM peeling for HMMH, improving both anatomical and functional outcomes.
ObjectiveTo systematically evaluate the effect of pars plana vitrectomy (PPV) combined total peeling of internal limiting membrane (ILM) versus fovea-sparing peeling of ILM for myopic foveoschisis. MethodsA evidence-based medicine study. Chinese and English as search terms for myopic foveoschisis, vitrectomy, and peeling of internal limiting membrane were used to search literature in China National Knowledge Infrastructure, Wanfang database, VIP database, PubMed of National Library of Medicine, Medline, Embase, and Cochrane Library. The high myopic macular schisis was selected as the research object, the intervention method was PPV combined with complete ILM peeling and combined with foveal preservation ILM peeling surgery clinical control study between Jan 1, 2010, and Jun 31, 2021. Incomplete or irrelevant literature and review literature were excluded. The method of Newcastle-Ottawa Scale system was used to evaluate the included literature. The literature was meta-analyzed by RevMan5.3 software. The mean difference (MD) and a confidence interval (CI) of 95% were used to describe the effect sizes of continuous data, fixed effects model was performed. The data including the best corrected visual acuity (BCVA), central fovea thickness (CFT), and postoperative macular hole (MH) were analyzed. ResultsIn those databases, 232 articles based search stratery were totally retrieved, and 10 articles (417 eyes) were finally included for meta-analysis with 245 eyes for PPV combined total peeling of ILM and 172 eyes for PPV combined fovea-sparing peeling of ILM. Meta-analysis results showed there was no significant difference in BCVA and CFT between the two groups (BCVA: MD=0.05, 95%CI 0.00-0.11; P＞0.05; CFT: MD=－4.79, 95%CI －18.69-9.11, P＞0.05). It was compared with the incidence of MH, the difference was statistically significant (odds ratio=5.70, 95%CI 2.22-14.61, P＜0.05). ConclusionBCVA and CFT could be improved by PPV combined total and fovea-sparing peeling of ILM for myopic foveoschisis; compared with complete ILM peeling, the incidence of MH was lower after foveal-sparing ILM peeling.
ObjectiveTo observe the efficacy of platelet-rich fibrin (PRF) membrane tamponade combined with air filling for giant macular hole (MH). MethodsA prospective case-control study. From January 2019 to February 2021, 56 patients (56 eyes) diagnosed with giant MH from Eye Center of Renmin Hospital of Wuhan University were enrolled. Among them, there were 17 males with 17 eyes and 39 females with 39 eyes. The average age of the patients was 64.23±9.30 years old. The average MH minimum diameter was 827.36±83.16 μm. The best corrected visual acuity (BCVA) and optical coherence tomography angiography (OCTA) examination were performed before surgery. The Chinese version of 25-item National Eye Institute visual functioning questionnaire (NEI VFQ-25) was used to investigate patient's visual-related quality of life. There were 28 eyes of 28 cases receiving PRF membrane covering, as PRF group, another 28 eyes of 28 cases receiving inverted internal limiting membrane (ILM) insertion into giant MH, as ILM group. The differences of the age (t=－1.588), sex ratio (χ2=0.760), BCVA (Z=－0.400), macular hole minimum diameter (t=－0.604), choriocapillary blood flow area (CBFA) (t=1.331) and NEI VFQ-25 score (t=0.921) were not statistically significant (P＞0.05). All eyes underwent 23G minimally invasive vitrectomy. In the PRF group, PRF membrane was used to fill the hole, and in the ILM group, the hole was filled with ILM inversion, and filled with sterile air after full gas-liquid exchange. The follow-up time after surgery was ≥6 months. The same equipment and methods as before surgery were used to conduct related examinations, and the changes of BCVA, the shape of hole closure, CBFA and the improvement of vision-related quality of life were compared between the two groups. For comparison between groups, independent samples t-test was used for data with normal distribution, and Mann-Whitney U test was used for data with non-normal distribution. For intra-group comparisons, paired-samples t-test was used for data with normal distribution, and Wilcoxon rank-sum test was used for non-normally distributed data. ResultsSix months after surgery, in the eyes of PRF group and ILM group, the hole of 27 (96.4%, 27/28) and 26 (92.6%, 26/28) eyes were closed; the median BCVA was 0.70 and 0.70, respectively; CBFA were 1.99±0.20 and 1.91±0.18 mm2; NEI VFQ-25 scores were 81.36±12.39 and 78.39±10.12, respectively. Compared with before surgery, the BCVA (Z=－4.636,－4.550) and CBFA (t=－27.115,－31.135) of the affected eyes in the PRF group and ILM group were significantly improved after surgery, and the NEI VFQ-25 scores (t=－15.557, －10.675) was significantly increased, and the difference was statistically significant (P＜0.05). There was no significant difference in BCVA (Z=－0.167), CBFA (t=1.554), and NEI VFQ-25 scores (t=0.980) between the two groups after interocular surgery (P=0.726, 0.126, 0.331). ConclusionPRF membrane insertion with air filling has the same efficacy as ILM insertion in the treatment of giant MH, which can improve the closure rate of MH, patients' vision and vision-related quality of life, and increase choroidal blood perfusion.
Vitreoretinal interface is consisted of posterior vitreous cortex, retina internal limiting membrane, and extracellular matrix between them. Basement membrane-like complex is formed in the interface. The interface in children is of much difference with that in adult. The adhesion of it is much tight in children. The posterior edge of vitreous base is closed to ora serrata. The retina internal limiting membrane is thin. But with age, the posterior margin of vitreous base extends posteriorly, internal limiting membrane thickens and its elasticity decreases, the adhesion in vitreoretinal interface weakens, and posterior vitreous detachment develops. To recognize fully the interface in children is of much importance for understanding the pathophysiology and treatment strategy of pediatric vitreoretinal diseases.
Objective To observe the clinical effects of pars plana vitrectomy (PPV) combined with internal limiting membrane (ILM) peeling and C3F8 tamponade for patients with highly myopic macular hole (HM-MH) with and without foveoschisis. MethodsA retrospective case controlled study. From January 2017 to February 2022, 23 eyes of 23 patients with highly myopic macular hole with and without foveoschisis diagnosed in the Shandong Eye Hospital were included in the study. Among them, 5 males had 5 eyes, and 18 females had 18 eyes, the age was (54.43±12.96) years old. The patients with or without foveoschisis were 12 eyes in 12 cases and 11 eyes in 11 cases. Studies were divided into two groups, depending on the presence of a concomitant myopic foveoschisis or not. The groups are high myopia macular hole with foveoschisis (group A) and high myopia macular hole without foveoschisis (group B). Best-corrected visual acuity (BCVA), B-scan ultrasonography, optical coherence tomography and axial length (AL) measurement were performed in all eyes. Snellen chart was used for BCVA examination, and the visual acuity was converted into logarithm of minimum angle of resolution (logMAR) during statistics. The age of the two groups, sex, macular hole (MH) diameter, logMAR BCVA, AL, posterior scleral staphyloma, there was no significant difference (P＞0.05). PPV combined with ILM peeling and C3F8 filling were performed in all eyes. Follow-up was at least 3 months after the last operation. BCVA changes and MH closure were compared between the two groups after surgery. Wilcoxon test was used to compare BCVA before and after operation. Mann-whiteny U test was used to compare preoperative and postoperative BCVA between groups. ResultsAfter initial surgery, MH was closed in 17 of 23 eyes (74%, 17/23). MH was closed in 8 eyes in group A (66.7%, 8/12). Four eyes were not closed (33.3%, 4/12); MH closed in 9 eyes in group B (81.8%, 9/11). There was no significant difference between the two groups after initial operation (P＞0.05). At 1 and 3 months after surgery, the logMAR BCVA of patients in group A and group B were 1.00±0.46, 1.03±0.83 and 0.53±0.63, 0.55±0.41, respectively. Compared with before operation, there was no significant difference at 1 month (P=0.783, 0.358), but the difference was statistically significant at 3 months (P=0.012, 0.007). There was no significant difference in logMAR BCVA between group A and group B at 1 and 3 months after operation (P=0.687, 0.950). ConclusionPPV combined with ILM peeling and C3F8 tamponade can promote MH closure and improve visual acuity in most affected eyes with HM-MH with and without foveoschisis.