Pars plana vitrectomy has evolved as the standard for the treatment of full-thickness macular holes (FTMHs) since the first reports by Kelly and Wendel.1 Several preoperative, intraoperative, and postoperative factors may influence anatomic and functional success rates of FTMH surgery.2,3

Spiteri et al. performed a meta analysis of more than 300 subjects enrolled in prospective studies in a study to determine whether internal limiting membrane (ILM) peeling improves anatomic and functional outcomes of FTMH surgery when compared with the no-peeling technique. Although no differences in distance visual acuity were observed long term between subjects with FTMH in whom the ILM was peeled when compared with those in whom the ILM was left in situ, they found that ILM peeling achieved higher anatomic success with a reduced need for additional surgical interventions.4,5

These studies have created a widespread trend toward peeling the ILM during FTMH surgery. The main rationale for ILM peeling is to relieve tractional forces occurring around the fovea while eliminating a scaffold for postsurgical epiretinal membrane formation.6 Peeling the ILM is the most challenging step in FTMH surgery. The 2.5-µm thick membrane is intimately incorporated into the retina, and the surgeon must take care to minimize trauma to the retina while removing the ILM. Various techniques, dyes, such as indocyanine green (ICG) and brilliant blue G, and surgical instruments, such as the Finesse Flex Loop (Alcon), have been developed in recent years to facilitate such procedures.

Case Report

Figure 1. Spectral-domain OCT. (A) Vitreomacular traction after cataract surgery; (B) full-thickness macular hole; (C) 1 month after vitrectomy cutter-only ILM peel.

A 65-year-old woman without systemic illness presented with vitreomacular traction (Figure 1A) in the setting of mild myopia post cataract extraction and IOL placement. She developed a FTMH (Figure 1B) in the involved left eye with associated best-corrected visual acuity (BCVA) of 20/200.

We performed microincisional vitrectomy surgery using a Constellation Vision System (Alcon) and a valved 23-gauge cannula set. Once the cannulas were introduced, we performed a central and peripheral vitrectomy using the Resight (Carl Zeiss Meditec) indirect wide-angle viewing system that allows easier peripheral manipulation of the vitreous. Complete removal of the posterior hyaloid was performed.

Figure 2. (A) The surgeon creates a break in the ILM using a cutteronly technique; (B) peeling of the ILM over the FTMH using the vitrector probe.

After staining the ILM with ICG, we used the cutter to create a break in the ILM using suction only (Figure 2A). Once the initial break was created, we peeled the ILM over the FTMH using the cutter only (Figure 2B). After releasing all tangential forces in the macula, we performed a gas tamponade.

Six weeks postoperatively, the patient’s BCVA had improved to 20/60 in the left eye and optical coherence tomography confirmed closure of the FTMH with some resolving intraretinal fluid (Figure 1C). Three years after surgery, the patient’s FTMH remained closed without the need for further intervention and BCVA improved to 20/40 in the left eye.

Conclusion

The Constellation Vision System enables the surgeon to modify duty cycle to control flow independent of vacuum and cut rate. The intraocular pressure (IOP) compensation feature provides control of infusion pressure, resulting in more stable IOP. These features enable the surgeon to work with the cutter close to the retina with an improved safety margin. Using valved trocars further improves these features. This technology allowed us to safely peel the ILM without touching the retina.

The technique presented in this short report may limit tissue microtrauma and could minimize the risk of postsurgical complications. We have found this technique is possible with the 23-, 25-, and 27-gauge vitrector probe. Not all cases can be performed in such fashion, however, because of variable vitreoretinal interface anomalies. Currently, we use intraoperative OCT to image the macula before and after ILM peeling. At this time, we still use ILM staining and gas tamponade. Future technologies may enable us to tailor our techniques to provide better visual and anatomic outcomes. Further studies are needed to better understand the physiology and outcomes associated with FTMH surgery. n

Editorially independent supported by advertising from Alcon and Topcon.

1. Kelly NE, Wendel RT. Vitreous surgery for idiopathic macular holes. Results of a pilot study. Arch Ophthalmol. 1991;109:654-659.

2. Duker JS, Kaiser PK, Binder S, et al. The International Vitreomacular Traction Study Group classification of vitreomacular adhesion, traction, and macular hole. Ophthalmology. 2013;120:2611-2619.

3. Ripandelli G, Rossi T, Scarinci F, et al. Macular vitreoretinal interface abnormalities in highly myopic eyes with posterior staphyloma: 5-year follow-up. Retina. 2012;32:1531-1538.

4. Spiteri Cornish K, Lois N, Scott N, et al. Vitrectomy with internal limiting membrane (ILM) peeling versus vitrectomy with no peeling for idiopathic full-thickness macular hole (FTMH). Cochrane Database Syst Rev. 2013;6:CD009306.

5. Spiteri Cornish K, Lois N, Scott NW, et al. Vitrectomy with internal limiting membrane peeling versus no peeling for idiopathic full-thickness macular hole. Ophthalmology. 2014;121:649-655.

6. Almony A, Nudleman E, Shah GK, et al. Techniques, rationale, and outcomes of internal limiting membrane peeling. Retina. 2012;32:877-891.

Victor M. Villegas, MD
• assistant professor at Bascom Palmer Eye Institute, Miami, and joint faculty at the University of Puerto Rico
• no relevant financial relationships to disclose
• v.villegas@med.miami.edu

Aaron S. Gold, OD
• director of optometric services at Murray Ocular Oncology & Retina, Miami
• no relevant financial relationships to disclose
• agold@murraymd.com

Timothy G. Murray, MD, MBA
• founding director and CEO of Murray Ocular Oncology & Retina, Miami
• tenured professor emeritus in ophthalmology and radiation oncology with the Bascom Palmer Eye Institute/Sylvester Comprehensive Cancer Center, Miami
• consultant for Alcon
• tmurray@murraymd.com