|Year : 2003 | Volume
| Issue : 3 | Page : 251-254
Does Internal Limiting Membrane Peeling in Macular Hole Surgery Improve Reading Vision?
T Das, S Parida, Ajit B Majji
Smt Kanuri Santhamma Retina Vitreous Center, L V Prasad Eye Institute, Hyderabad, India
Smt Kanuri Santhamma Retina Vitreous Center, L V Prasad Eye Institute, Hyderabad
Source of Support: None, Conflict of Interest: None
Purpose: To document the effect of internal limiting membrane (ILM) peeling in macular hole closure and reading vision.
Method: Fifty-four patients with idiopathic and traumatic macular hole underwent standard vitreous surgery and received either ILM peeling (n= 25) or no ILM peeling (n= 29). The hole closure, and Snellen acuity (distant and near) were recorded 12 weeks after surgery and statistically analysed. Results: The macular hole closure rate was 96% (24 of 25) and 72.4% (21 of 29) with and without ILM peeling respectively (P = 0.028). Distant vision improvement of two or more lines was recorded in 64% (16 of 25) and 51.7% (15 of 29) eyes (P = 0.417) with and without ILM peeling respectively. Near vision improvement of two or more lines was seen in 68% (17 of 25) and 41.2% (12 of 29) eyes (P = 0.048) with and without ILM peeling respectively. Conclusion: ILM peeling in macular hole surgery improves the macular hole closure rate and reading vision.
Keywords: Macular hole surgery, ILM peeling, reading vision
|How to cite this article:|
Das T, Parida S, Majji AB. Does Internal Limiting Membrane Peeling in Macular Hole Surgery Improve Reading Vision?. Indian J Ophthalmol 2003;51:251-4
Kelly and Wendel first demonstrated that vitreous surgery with removal of posterior hyaloid vitreous traction followed by intraocular injection of long-acting gas and remaining in a face-down position for a couple of weeks closes the idiopathic macular hole. Since then there have been several publications, one randomised controlled clinical trial ,, and one technology assessment article.  Several modifications have been suggested to increase the closure rate of the macular hole or increase the comfort of the patients. They include use of biologic or pharmacologic adjunctive agents, ,, silicone oil, and no face down position,  and only air injection with limited face down position. These suggested modifications, at best, have achieved only limited acceptance. With the current technique of complete vitrectomy including removal of posterior hyaloid, fluid-gas exchange, and face down position, the macular hole closure rate has increased from 58% to over 90%, and 22 to 49% patients obtain 6/12 (20/40) or better visual acuity. ,
While the current level of evidence does not support any adjuvant therapy in macular hole surgery,  the internal limiting membrane (ILM) peeling is considered necessary to improve the anatomical and functional success. ,, In all studies the distant Snellen acuity alone is measured to define functional success, and the near acuity is often ignored. In this communication we compare the hole closure rate and the visual acuity changes (both distant and near) with and without ILM peeling in macular hole surgery.
| Materials and Methods|| |
This retrospective chart analysis included 54 patients (54 eyes) operated for either idiopathic or traumatic full thickness macular hole at LV Prasad Eye Institute, Hyderabad, India, from December 1995 to December 2000. Holes associated with diabetic retinopathy, vasculitis, and retinitis pigmentosa were excluded from this study. The data were collected from the medical and surgical records of these patients. Two retinal surgeons performed all the surgeries and the decision regarding ILM peeling was left to the discretion of the operating surgeon.
The preoperative data included demography, duration of symptoms, best corrected visual acuity (distant and near), Amsler grid, slitlamp biomicroscopy, fundus biomicroscopy, indirect ophthalmoscopy and review of the fundus photograph. The distant vision was recorded by Snellen acuity chart placed at 6 meters, and the near vision was recorded using the near acuity chart at 33 cms. Staging of the macular hole was made as per the recommendation of Gass14,15 and hole size was measured by each surgeon preoperatively either during slitlamp examination using the nearby vessel caliber as a measuring index or in the later part of the study using optical coherence tomograph (OCT). The surgical details collected from the surgery register included the method of induction and separation of the posterior hyaloid face, ILM peeling if any, use of indocyanine green (ICG) dye for peeling, and the nature of tamponade. The postoperative data included detailed eye examination, measurement of best corrected distant and near visual acuity in the last follow-up, and evaluation of the fundus photograph.
All patients received standard three port pars plana vitrectomy, posterior hyaloid removal, and non-expensile concentration of long-acting gas (C3F8 14%) or silicone oil tamponade. Following core vitrectomy, the suction was raised to 250-300 mm Hg, and posterior hyaloid separation was done either with a soft tip cannula or the vitreous cutter (using suction mode alone). One ml of 0.6% sodium fluorescein was injected into the vitreous cavity to stain the clear vitreous. This temporarily stains the clear vitreous green, and enables complete removal of the peripheral skirt of vitreous. (Das T. Vail Vitrectomy Meeting, 2000, unpublished). Vitreous base surgery was not done in any eye. In the initial part of the study ILM peeling was done without assistance of dye, and later indocyanine green dye (0.5 ml; 2.5 mg in 1 ml) was used to stain and facilitate the ILM peeling. The peeling was confined to one disc area around the macular hole. The surgery was completed, with fluid-air exchange, and finally with injection of 40 ml 14% C3F8 gas. Silicone oil (1300 cs) was used in three eyes instead of gas. These patients with phakic eyes had severe orthopetic problems to maintain face down pasture for a long time. The patients with gas tamponade were advised to maintain prone posture for 2 weeks; the patients with silicone oil were requested to maintain prone posture (if possible) for one night only, and subsequently lateral (macula up) posture till the oil was extracted from the eye.
The patients were examined on postoperative day 1, week 1, month 1, month 3, and every three months thereafter. At every visit the examination included slitlamp biomicroscopy, fundus biomicroscopy, applanation tonometry, indirect ophthalmoscopy and fundus photography. The Snellen distant and near vision were recorded at one month and subsequently all the eyes were refracted and appropriate spectacles correction prescribed.
Anatomical closure was defined as approximation of the edges of the macular hole as seen in fundus biomicroscopy and fundus photography. Functional success was defined as increase in best corrected visual acuity by 2 or more lines for distance and near.
Fisher's exact test was used to compare the hole closure rate and change in visual acuity in eyes that received ILM peeling. A P-value of less than 0.05 was considered significant.
| Results|| |
In the study group, 37 (68.5%) patients had idiopathic macular hole, and 17 (31.48%) patients had macular hole secondary to trauma. Twenty-seven (50%) patients each had stage 2 and stage 3 macular holes. The mean age of patients with traumatic holes was 23.9 ± 11.6 years (range 11 - 53 years), and the mean age of patients with idiopathic holes was 59.3 ± 8.8 years (range 39-74 years). In the idiopathic group, 28 (75.6%) were females, and in the traumatic group 15 (88.2%) were males. The mean duration of symptoms was 260 days in the idiopathic group and 45 days in the traumatic group. ILM peeling was done in 25 eyes and not done in 29 eyes.
Anatomical and functional results
In the entire group 45 (83.3%) of 54 macular holes closed after one surgery. The macular hole did not close in nine (16.7%), and none of the patients agreed to a second surgery. In the idiopathic group 30 (81.1%) of 37 and in the traumatic group 13 (82.3%) of 17 macular holes closed. There was no statistical difference in macular hole closure rate between the two groups (P = 1.0, Fisher's exact test)
Distant vision: In the idiopathic group distant vision improved in 21(56.7%), remained unchanged in 6 (16.2%) eyes, and worsened in 10 (27%) of 37 eyes. In the traumatic group vision improved in 10 (58.8%) eyes, remained unchanged in 6 (35.3%) and worsened in 1 (6%) of 17 eyes. There was no statistical difference in distant vision changes between the two groups (P = 1.0, Fisher's exact test) [Table - 1].
Near vision: In the idiopathic group near vision improved in 18 (48.6%) eyes, remained unchanged in 11 (29.7%), and worsened in 8 (21.6%) of 37 eyes. In the traumatic group the near vision improved in 10 (58.8%), remained unchanged in 3 (17.6%) eyes, and worsened in 4 (23.5%) of 17 eyes. There was no statistical difference between two groups (P = 0.56, Fisher's exact test) in the near vision changes [Table - 1].
Influence of hole stage : Stage 2 macular hole closed in 26 (96.3%) eyes; distant vision improved in 19 (70.4%) eyes and near vision improved in 16 (59.2%) of 27 eyes. Stage 3 hole closed in 20 (74.1%) eyes; distant vision improved in 17 (63%) eyes and near vision improved in 12 (44.4%) of 27 eyes.
Influence of ILM peeling : In the ILM peeled group, the macular hole closed in 24 (96%) of 25 eyes; in the ILM non-peeled group the macular hole closed in 21 (72.4%) of 29 eyes. This was statistically significant (P = 0.028; Fishers'exact test). In the ILM peeled group, the distant vision improved in 16 (64%) of 25 eyes, remained unchanged in 4 (16%) of 25 eyes, and worsened in 5 (20%) of 25 eyes. In the ILM non-peeled eyes the distant vision improved in 15 (51.7%) of 29 eyes, remained unchanged in 8 (27.6%) eyes, and worsened in 6 (20.7%) of 29 eyes. This was not significant statistically (P = 0.41; Fisher's exact test). In the ILM peeled group, the near vision improved in 17 (68%) of 25 eyes, remained unchanged in 3 (12%) of 25 eyes, and worsened in 5 (20%) of 25 eyes. In the ILM non-peeled group the near vision improved in 12 (41.4%) of 29 eyes, remained unchanged in 10 (34.5%) eyes, and worsened in 7 (24.1%) of 29 eyes. This was statistically significant (P = 0.048; Fisher's exact test) [Table - 2].
Complications : Progressive nuclear sclerosis was seen in 14 (25.9%) of 54 eyes. Inferior retinal detachment developed in an eye with traumatic macular hole; this eye received retinal reattachment surgery twice, but without success.
| Discussion|| |
Successful macular hole surgery relies on the relief of tangential traction on the macula, described by Gass., Kelly and Wendel provided the early evidence that relief traction results in closure of the hole, and in improvement of vision. It was later realised that in addition to the posterior hyaloid any epiretinal and internal limiting membrane also exerts tangential traction on the macular hole. Relief of this traction is necessary to close the macular hole successfully. This is particularly evident in stage 4 macular holes where the posterior vitreous detachment has already occurred.
Some authors have demonstrated greater hole closure and functional gain with ILM peeling in macular hole surgery ,, while others have not., The benefits of ILM peeling in macular hole surgery has been both confirmed and denied., In all these studies the distant vision only has been considered to define functional success and near vision (reading vision) is not considered.
While it can be argued that the near vision and distant vision are directly proportional, there are several situations where near vision could be better than the distant vision. But the importance of near vision cannot be denied in elderly presbyopic individuals who usually develop idiopathic macular holes.
Our study demonstrates that peeling of the internal limiting membrane improves the hole closure rate. While improvement in distant vision whether one peels or does not peel the ILM in macular hole surgery was similar, this study demonstrated that the near vision improved significantly when the ILM was peeled. The ILM was peeled without use of ICG dye at first, and later ICG was used in all cases where the ILM was peeled. It was observed that identification of the ILM was easier with use of the ICG dye and that the peeling was less traumatic. Though 2.5% concentration of ICG dye and contact time of 2 minutes are recommended for intravitreal use, the short and long-term toxicity on the retina is not documented. Since our results did not differ between eyes with and without dye-assisted ILM peeling, and because ILM peeling was technically easier when stained with the ICG dye, we would like to presume that ICG assisted ILM peeling was not harmful to the eye. However, in absence of a randomised trial of dye assisted and non-assisted ILM peeling the benefits of ICG staining or otherwise of the ILM can not be ascertained. The other weakness of the study was that the ILM peeling was not randomised.
To conclude, the hole closure rate was significantly greater in eyes that received ILM peeling, and this benefit was seen in both idiopathic and traumatic macular holes. While gain in distant vision was unaffected whether or not the ILM was peeled, the near vision improvement was apparently greater with ILM peeling.
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[Table - 1], [Table - 2]
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