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Update on Membrane Peeling Techniques Today
Bopp S., Lucke K.,
Tagesklinik Universitätsallee GmbH, Augenabteilung (Bremen)
Since vitreous surgery was introduced over 20 years ago, peeling of epiretinal membranes has become an essential surgical maneuver. Classic indications are macular pucker, proliferative vitreoretinopathy (PVR) and vasoproliferative diseases. The main goals of membrane removal are relief of traction on the fovea and mobilization of contracted detached retina. Until recently, identification and removal of fibroglial or fibrvascular tissue were guided by ophthalmoscopically visible structures. A new era of diagnostics properties and treatment options for vitreoretinal diseases evolved when surgery for macular holes was introduced. The scientific interest was focussed on subtle alterations of the vitreoretinal interface around the hole. High resolution optics for OR microscopes, delicate vitreous instruments for atraumatic peeling maneuvers and intravitreally applied dyes (ICG, trypan blue) for better visualization of the vitreoretinal interface are the latest tools for advanced membrane removal. New non-invasive examination methods (especially the OCT) can measure macular alterations with high sensitivity and resolution. These new insights were applied to other macular disorders, such as cellophane maculopathy, lamellar holes and macular edema of various origins. The new term traction maculopathy reflects that a common pathogenic pathway can be assumed for these conditions. Morphologic studies on excised membranous material have silenced the skepticism that ILM can be removed intentionally. ICG-guided ILM-peeling has contributed to achieve macular hole closure in over 95%, shown effective traction removal in cellophane maculopathy and led to impressive resolution of cystoid macular edema in some indication groups. A new application of dye-enhanced vitreous surgery has been found in retinal detachments and PVR. Today, vitreous surgeons are aware of the exciting advances in peeling techniques. At the same time, however, the new methods need scientific evaluation. The role of (pathologically altered) ILM in various diseases and the underlying mechanisms for edema resolution remain unclear. Most important at the moment is to establish the risk/benefit ratio of ILM-peeling in various clinical entities (indications & patient selection) and to clarify the debate about toxicity of the in-vivo staining substances.