Abstract
Purpose
To present two patients who underwent surgery for an idiopathic macular hole (IMH) with internal limiting membrane (ILM) peeling and developed an epimacular proliferative response.
Methods
Observational case report. Two patients with an IMH underwent pars plana vitrectomy with ILM peeling. Ophthalmic examination including optical coherence tomography (OCT) was performed pre- and postoperatively. In both cases, scanning laser ophthalmoscopy (SLO) was performed postoperatively.
Results
In the first case, the closure of the macular hole (MH) was confirmed ophthalmoscopically and by OCT following the surgery. At 2 months postoperatively, a thin epiretinal membrane (ERM) developed over the nasal macula area where the ILM had been peeled. The patient’s visual acuity had recovered to 1.0 but she complained of metamorphopsia. At 18 months postoperatively, the thin ERM around the nasal fovea remained and her visual acuity was still 1.0. In the second case, the MH was sealed after the surgery, and the patient’s visual acuity had improved to 1.0 at 3 months, but an indistinct ERM developed in the macular region where the ILM had been peeled. Two years after the operation, her VA was still 1.0. One and two years postoperatively, a thin epimacular proliferation remained unchanged; in addition, the OCT and SLO images remained stable.
Conclusion
Two patients who underwent IMH surgery with ILM peeling developed an epimacular proliferative response postoperatively. We suggest that the injury associated with the ILM peeling may have stimulated glial proliferation.
Explore related subjects
Discover the latest articles, news and stories from top researchers in related subjects.Avoid common mistakes on your manuscript.
Introduction
The removal of the internal limiting membrane (ILM) during macular hole (MH) surgery has been widely advocated, and excellent anatomic success rates have been reported [1, 4, 6, 7]. It has been suggested that ILM peeling may signal glial cells to proliferate and lead to the sealing of the MH [2, 5]. Because the Müller cell footplates make up the outer part of the ILM, the Müller cells will probably sustain some degree of injury by the ILM peeling, and this injury may induce gliosis. We present the cases of two patients who underwent MH surgery with ILM peeling and developed an epimacular proliferative membrane postoperatively.
Case reports
Case 1
A 77-year-old woman presented with a complaint of metamorphopsia in her right eye of one month duration. Her visual acuity was 0.4 OD and 0.8 OS. Ophthalmoscopic examination and optical coherence tomography (OCT) showed a stage 4, full-thickness MH with a posterior vitreous detachment (PVD) (Fig. 1A), associated with a lesion of retinal pigment epithelial atrophy temporal to the macula (Fig. 2A). The patient underwent phacoemulsification and aspiration of the lens and pars plana vitrectomy (PPV). The ILM was stained with indocyanine green (ICG) [3] and was thoroughly removed for 3 disc diameters around the MH in a circular capsulorrhexis maneuver. An intraocular lens was inserted, and 20% sulfur hexafluoride (SF6) was injected into the vitreous cavity as a gas tamponade. A face-down position was maintained for 1 week.
One month after the operation, the patient’s VA was 0.4 and the MH was closed. At 2 months, a thin epiretinal membrane (ERM) had developed over the nasal macula area where the ILM had been peeled (Fig. 2B). OCT showed a highly reflective band over the nasal macular area that corresponded with the ERM. In addition, OCT demonstrated the absence of a foveal depression and the presence of low-reflective cystoid spaces within the macula (Fig. 1B).
Eighteen months after the operation, the patient’s VA had recovered to 1.0 but she complained of metamorphopsia. The OCT image was partly changed; the normal contour of the foveal pit was absent but macular thickness was slightly decreased following the reduction of the low-reflective cystoid spaces within the macula (Fig. 1C). Fundus photographs and the scanning laser ophthalmoscopic (SLO) images showed a thin ERM around the nasal macula (Fig. 2C,D).
Case 2
A 44-year-old woman was referred for declining visual acuity (0.4) in her left eye of 3 months’ duration. Funduscopic examination revealed a stage 2, full-thickness MH without a PVD. Two weeks later, fundus examination and OCT showed a stage 3, full-thickness MH without a PVD (Figs. 3A, 4A). PPV combined with ILM peeling with ICG staining [3] was performed for 2.5 disc diameters around the MH. Then, fluid–air exchange with room air tamponade was performed.
Two months after surgery, the patient’s VA was 0.8 and the MH was closed. Three months postoperatively, her VA had improved to 1.0 and an indistinct ERM had developed in the macular region (Fig. 4B). OCT showed a highly reflective membrane surrounding the macula, and the macula was flat and sunken with steep edges (Fig. 3B). Examination with the SLO showed a thin and well-demarcated ERM at the macula and also showed the area of the ILM peeling around the MH (Fig. 4E). Two years after the operation, the patient’s VA was still 1.0. One and two years postoperatively, a thin epimacular proliferation remained unchanged (Fig. 4C,D); in addition, the OCT and SLO images remained stable (Figs. 3C, 4F).
Discussion
These patients with postoperative proliferative responses over the macular area were 2 of 44 consecutive cases that had undergone MH surgery with ILM peeling between August 1998 and April 2001 in our institution. Thus, we believe that such proliferative responses cannot be attributed to an initial learning effect for the ILM peeling. We had performed more than 135 MH surgeries without ILM peeling from 1994 through 1998 before the ILM peeling was introduced, and no such postoperative proliferation has ever been observed in any of them. Similarly, postoperative proliferation was not reported in the 170 eyes that underwent vitrectomy with removal of the adherent cortical vitreous and stripping of epiretinal membranes but no ILM peeling [8]. However, in support of our finding, a postoperative ERM has been reported in 3 of 58 eyes that underwent vitrectomy for MH with ILM peeling. ILM peeling is considered to defuse the contractile forces produced by the glial cells that migrate onto the ILM surface and play a role in the formation and enlargement of the MH. However, in the process of peeling the ILM, the Müller cell footplates will most likely sustain some degree of injury. Histopathological studies have shown that the Müller cells and fibrous astrocytes proliferate and seal an MH following the removal of the cortical and epicortical vitreous, and/or the peeling of the ILM [5]. Thus, the postoperative ERM may have been made up of the glial cells that migrated onto the macular surface through a defect in the ILM [5]. With the available data, we suggest that the injury associated with the ILM peeling promotes glial proliferation. Additional studies are needed to evaluate the efficacy of the ILM peeling.
References
Books HL (2000) Macular hole surgery with and without internal limiting membrane peeling. Ophthalmology 107:1939–1949
Funata M, Wendel RT, de la Cruz Z, Green WR (1992) Clinicopathologic study of bilateral macular holes treated with pars plana vitrectomy and gas tamponade. Retina 12:289–298
Kadonosono K, Itoh N, Uchio E, Nakamura S, Ohno S (2000) Staining of internal limiting membrane in macular hole surgery. Arch Ophthalmol 118:1116–1118
Kwok AK, Li WW, Pang CP, Lai TY, Yam GH, Chan NR, Lam DS (2001) Indocyanine green staining and removal of internal limiting membrane in macula hole surgery: histology and outcome. Am J Ophthalmol 132:178-183
Madreperla SA, Geiger GL, Funata M, de la Cruz Z, Green WR (1994) Clinicopathologic correlation of a macular hole treated by cortical vitreous peeling and gas tamponade. Ophthalmology 101:682–686
Mester V, Kuhn F (2000) Internal limiting membrane removal in the management of the full-thickness macular holes. Am J Ophthalmol 129:769-777
Park DW, Sipperley JO, Sneed SR, Dugel PU, Jacobsen J (1999) Macular hole surgery with internal-limiting membrane peeling and intravitreous air. Ophthalmology 106:1392-1397 (discussion 1397–1398)
Wendel RT, Patel AC, Kelly NE, Salzano TC, Wells JW, Novack GD (1993) Vitreous surgery for macular hole. Ophthalmology 100:1671–1676
Author information
Authors and Affiliations
Corresponding author
Additional information
Proprietary interest: None of the authors or any of their family members has any proprietary or financial interest in the instruments used in this study
This study has not been published elsewhere or presented at any meeting
Rights and permissions
About this article
Cite this article
Uemoto, R., Yamamoto, S. & Takeuchi, S. Epimacular proliferative response following internal limiting membrane peeling for idiopathic macular holes. Graefe's Arch Clin Exp Ophthalmol 242, 177–180 (2004). https://doi.org/10.1007/s00417-003-0804-8
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00417-003-0804-8