Elsevier

Survey of Ophthalmology

Volume 53, Issue 4, July–August 2008, Pages 368-396
Survey of Ophthalmology

Diagnostic and Surgical Techniques
Internal Limiting Membrane Peeling in Vitreo-retinal Surgery

https://doi.org/10.1016/j.survophthal.2008.04.006Get rights and content

Abstract

Peeling the internal limiting membrane of the retina has become a very common procedure performed by vitreo-retinal surgeons. The combination of new microsurgical instrumentation with the availability of different dyes to stain this thin and transparent membrane has facilitated the performance of internal limiting membrane peeling, reducing the time and trauma associated with this maneuver. Internal limiting membrane peeling has been used to treat a variety of retinal pathologies, including full-thickness macular hole, epiretinal membrane, macular edema, vitreomacular traction syndrome, and Terson syndrome, among others. Although it appears that peeling the internal limiting membrane in these retinal conditions may be associated with better anatomical and visual outcomes following surgery, further evidence through randomized controlled clinical trials is still needed to guide the vitreo-retinal surgeon on the appropriate use of this surgical maneuver.

Introduction

The internal limiting membrane (ILM) represents the structural boundary between the retina and the vitreous. It is a periodic acid schiff (PAS)-positive basement membrane. It has a smooth inner (vitreal) surface and an irregular retinal surface, in close apposition with the plasma membrane of the Müller cells. The close association of the ILM and the Müller cells suggests that the ILM derives from these cells.65 The ILM is thickest posteriorly, in the parafoveal and peripapillary regions, and measures an average of 2.5 μm in thickness.66

In a study to investigate the role of the ILM in the survival of ganglion cells (GCs) in the embryonic chick and mouse embryo, it was observed that most GCs underwent apoptotic cell death when the ILM was removed at the embryonic day 5.110 Reconstitution of the ILM rescued most of the GCs from cell death. GC death in vivo was always accompanied by the retraction of radial cell (neuroepithelial cells and Müller glia cells) processes, and GCs were rescued by keeping radial cell retraction to a minimum.110 This suggested that the ILM was involved in GCs survival by anchoring the radial cells end feet to the vitreal surface of the retina, bringing GCs and end feet of radial cells in contact with each other. As the connection to the radial cell end feet was lost, GCs died. GCs survived when the ILM was removed slightly later, at the embryonic day 7. By embryonic day 7, the radial cells no longer need the ILM to extend their processes throughout the retina, providing further evidence to support the above hypothesis. In the aged human eye, the removal of the ILM has no obvious detrimental effects found to date, suggesting that the ILM may have its main function during early embryogenesis.110

Given the difficulties encountered to investigate the healing process that occurs following ILM peeling in humans, this phenomenon has been studied in non-human primates, and it was found that up to 12 months following peeling of the ILM no regeneration of this membrane was observed.272 However, healing of the ILM-debrided area occurred in the form of stretching and flattening of neighbouring Müller cell processes in addition to reactive gliosis over the nerve fibres in the denuded area.272

Section snippets

Historic Review

The ILM received virtually no clinical attention until vitrectomy for removal of epimacular proliferation became a routine surgical procedure in the 1980s, when ILM fragments were often identified during routine histological evaluation of surgical specimens.193 In 1990, Morris and colleagues presented at the Annual Meeting of the American Academy of Ophthalmology a series of cases in which intentional ILM removal was performed in patients with Terson syndrome and sub-ILM macular hemorrhages. In

Idiopathic FTMH

Anteroposterior vitreomacular traction has been suggested as a possible mechanism implicated in the development of idiopathic FTMH.100, 165 However, it is also accepted that tangential vitreomacular traction, due to contraction of the prefoveal vitreous, plays a role on its pathogenesis.96, 97, 109, 166 It has been postulated that the posterior wall of premacular pockets of liquefied vitreous could cause tangential traction at the macula which could be responsible for idiopathic FTMH formation.

Complications of Internal Limiting Membrane Peeling

Some complications reported following ILM peeling techniques are known to occur also following non-ILM peeling PPV, including retinal tears,27, 35, 49, 50, 195, 196, 289, 319, 325, 363, 367 retinal detachment,16, 27, 35, 40, 50, 84, 91, 103, 121, 122, 171, 182, 196, 205, 206, 208, 212, 231, 243, 289, 329, 363, 367 progression of cataract,4, 16, 35, 40, 50, 84, 182, 194, 195, 208, 212, 341, 363, 380 elevation of IOP,35, 103, 182, 208, 231, 243, 319, 325, 341, 367 visual field defects,35, 120, 121

Summary and Conclusions

ILM peeling is widely used now in vitreoretinal surgery to treat a variety of macular diseases. Although the data available to date seem to suggest that ILM peeling may improve the anatomical and functional results of the surgery in some retinal diseases, further evidence through RCT is needed to support the use of this maneuver and to provide information with regard to the indications for its use.

Method of Literature Search

The authors conducted a search of the Medline (from 1960–2007) and ISI (from 1986–2007) databases using the following key words: internal limiting membrane, ILM, internal limiting membrane peeling, internal limiting membrane staining, macular hole, epiretinal membrane, macular edema, indocyanine green, infracyanine green, trypan blue, triamcinolone acetonide, patent blue, and brilliant blue G. In addition, references quoted in the articles found through these databases were also included, if

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    The authors reported no proporietary or commercial interest in any product mentioned or concept discussed in this article. The authors would like to thank Dr James Mackenzie, Department of Neuropathology, Aberdeen Royal Infirmary-UK, for the histopathology illustrations in this review.

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