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Year : 1997  |  Volume : 45  |  Issue : 2  |  Page : 75-76

Macular and submacular surgery

Correspondence Address:
T Das

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Source of Support: None, Conflict of Interest: None

PMID: 9475024

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How to cite this article:
Das T. Macular and submacular surgery. Indian J Ophthalmol 1997;45:75-6

How to cite this URL:
Das T. Macular and submacular surgery. Indian J Ophthalmol [serial online] 1997 [cited 2021 Mar 8];45:75-6. Available from: https://www.ijo.in/text.asp?1997/45/2/75/15012

Modern vitreous surgery was a dream three decades the ago. Today it is ophthalmologist's most effective tool for treating posterior segment diseases. In the last three decades significant technical and technological advances have taken place in further refinement of the vitreous surgery. These advances have also helped one to understand the pathophysiological abnormalities of many common diseases. Finally the efforts of some of the brilliant and innovative surgeons have added entirely new dimensions to surgically treat a variety of complex vitreoretinal diseases.

Recent areas of development in vitreous surgery are the macular and submacular surgery. These include surgery for epi macular membrane, vitreomacular traction syndromes, cystoid macular oedema, macular hole and finally submacular haemorrhage and neovascular membranes. Some of these conditions were described over one hundred years ago for which no effective therapy was available. Continued search to understand the pathology and natural history of these diseases have been richly rewarded.

Surgery for idiopathic macular hole is an appropriate example. In 1987 it was considered untreatable[1], and four years later in 1991[2] the results of a pilot study amply demonstrated a skilled and refined microsurgical technique that changed the treatment approach to idiopathic macular hole. This also stimulated for reappraisal of the pathogenesis of macular hole and the vitreomacular interface.[3] Maculorrhexis is another example. Maculorrhexis is clean removal of a scroll of internal limiting membrane (ILM). This is now considered to vastly improve the anatomical and visual success in macular hole surgery in contrast to the reported belief in 1990.[4]

New and exciting development of vitreous surgery of 1990s include submacular surgery for subretinal haemorrhage and surgical removal of submacular neovascular membranes. Both mechanical and tissue plasminogen activator (tPA) assisted removal of subreinal haemorrhage have been reported[5]. The tPA assisted clot removal appears to have an edge over the mechanical removal of subretinal clots. The surgical outcome of removal of choroidal neovascular membranes in presumed ocular histoplasmosis (POHS) is reported superior to age related macular degeneration (ARMD), high myopia, and angioid streaks. The difference lies in preservation of retinal pigment epithelium (RPE) beneath fovea after removal of neovascular complex.

The technique and technology of macular and submacular surgery is changing constantly. However, the current treatment approaches mainly involve removal of aberrant tissue such as posterior hyaloid of vitreous, scroll of ILM around macula, and haemorrhagic clot or scar tissue beneath the macula. Very soon these approaches will be supplemented with replacement of healthy differentiated cells both for rescue and replacement of retinal photoreceptors and pigment epithelium.[6],[7] Concurrently low dose radiation and photodynamic therapy is gaining acceptance as an alternate treatment for subfoveal neovascular membrane complex. [8,9] This is likely to herald a new era and open new avenues for potential treatment of a variety of retinal diseases for which there is currently no effective treatment. This will probably see the use of pharmacological agents, retinal transplantation, gene therapy, and radiation therapy to achieve better therapeutic effect.

April 1995 was the silver jubilee year of vitreous surgery in human eye. Robert Machemer reminiscing the past and looking beyond the present wrote[10] "vitreous surgery is here to stay and is by no means at the end of its development; ...... mechanical limitations will surely be overcome by appropriate combinations with medications." This prophetic statement is currently applicable to macular and submacular surgery. With the better understanding of pathoanatomy and pathophysiology of the disease, so also with rapid refinement in surgical instrumentation and technique, the overall management has greatly improved. Now the greatest need is for a randomized prospective multicenter study which will allow one to determine the relative merit of a particular therapeutic approach for widespread use.

  References Top

Gass JDM. Stereoscopic Atlas of Macular Disease. Diagnosis ant Treatment. 1987. C V Mosby Company, St.Louis. pp. 692.  Back to cited text no. 1
Kelly NE, Wendel RT. Vitreous surgery for idiopathic macular holes: results of a pilot study. Arch Ophthalmol. 109:654-659, 1991.  Back to cited text no. 2
Gass JDM. Reappraisal of biomocroscopic classification of stages of development of a macular hole. Am J Ophthalmol. 119:752-759, 1995.  Back to cited text no. 3
Sivalingam A, Eagle RC, Duker JS, et al. Visual prognosis correlated with the presence of internal limiting membrane in histopathologic specimens obtained from epiretinal membrane surgery. Ophthalmology. 97:549-1552, 1990.  Back to cited text no. 4
Thomas MA. Vitrectomy surgery for subfoeal choroidal neovascularization and submacular hemorrhage. in Macular Surgery (ed) Bovino JA. 1994. Appleton & Lange. Norwalk. pp.135-163.  Back to cited text no. 5
Algvere PV, Berglin L, Gouras P, Sheng Y. Transplantation of fetal retinal pigment epithelium in age related macular degeneration with subfoveal neovascularization. Graefes Arch Clin Exp Ophthalmol. 232:707-716, 1994.  Back to cited text no. 6
Das T, del Cerro M, Lazar ES, et al. Transplantation of neural retinal cells in patients with retinitis pigmentosa. Invest Ophthalmol Vis Sci. 37: s 96, 1996.  Back to cited text no. 7
Chakravarthy U, Houston RF, Archer DB. Treatment of age - related subfoveal neovascular membranes by teletherapy: a pilot study. Br J Ophthalmol. 77:265-273, 1993.  Back to cited text no. 8
Husain D, Kramer M, Michaud N, et al. Photodynamic therapy (PDT) of experimental choroidal neovascularization(CNV) using benzoporhyrin derivative (BPD-MA): Dye delivery and treatment parameters. Invest Ophthalmol Vis Sci. 36: s 225, 1995.  Back to cited text no. 9
Machemer R. Reminiscences after 25 years of pars plana vitrectomy. (Editorial) Am J Ophthalmol. 119:505-510, 1995.  Back to cited text no. 10


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