SURGICAL OUTCOMES OF VITREOMACULAR TRACTION TREATED WITH FOVEAL-SPARING PEELING OF THE INTERNAL LIMITING MEMBRANE

Abstract

Purpose: To compare sensitivity of the retina after complete internal limiting membrane (ILM) peeling versus foveal-sparing ILM peeling in vitrectomy for vitreomacular traction syndrome.

Methods: This was a randomized, prospective, comparative study. Thirty-four eyes were randomized to undergo peeling with foveal sparing of the ILM (FS group) or complete peeling group. Foveal and perifoveal retinal sensitivity, visual acuity, and central macular thickness were the main outcome measures.

Results: Parafoveal retinal sensitivity exhibited a significant improvement in both the FS and complete peeling groups (+2.43 ± 0.82 dB and +1.79 ± 0.86 dB, respectively; P = 0.037). Significant improvements were observed in both visual acuity and central macular thickness in both groups. No cases of epiretinal membrane recurrence were observed in the FS group.

Conclusion: Both the FS and complete peeling surgical techniques are safe and yielded good anatomical and functional results; however, a significant difference in favor of FS was found in relation to the best-corrected visual acuity and perifoveal retinal sensitivity. Preservation of the foveal ILM disc allowed the anatomical restoration of the foveal architecture in most vitreomacular traction syndrome cases without signs of stiffening or ILM fibrosis over a follow-up period of 1 year.

Trial registration: ClinicalTrials.gov NCT02361645.

Conflict of interest statement

None of the authors has any financial/conflicting interests to disclose.

Figures

Fig. 1.

(A) Complete peeling of the ILM. In the foveal-sparing procedure (B), the ILM is grasped several times near the arcades and pulled in a centripetal fashion. The remaining floating flap is finally trimmed with the vitrectome.

Fig. 2.

Representative microperimetry image of a patient with VMT syndrome before (A) and 12 months after vitrectomy with peeling with foveal sparing of the ILM (B). The preoperative perifoveal retinal sensitivity (pFRS) was 9.5 dB, which increased to 14 dB at 12 months after surgery.

Fig. 3.

Representative microperimetry image of a patient with VMT syndrome before (A) and 12 months after vitrectomy with peeling with foveal sparing of the ILM (B). The preoperative perifoveal retinal sensitivity (pFRS) was 11 dB, which increased to 13.5 dB 12 months after surgery. Note the appearance of some areas with relative scotomata not present in the preoperative examination.

Fig. 4.

Representative OCT scans for four eyes that underwent vitrectomy with foveal sparing peeling of the ILM for VMT. In each quadrant, the upper image shows the preoperative appearances, and the lower image shows the appearance 12 months after surgery. The arrow indicates the residual ILM above the fovea. (A) A 70-year-old woman, preoperative BCVA: 0.52 logMAR (20/66); postoperative BCVA: 0.15 logMAR (20/28). (B) A 61-year-old woman, preoperative BCVA: 0.39 logMAR (20/49); postoperative BCVA: 0.07 logMAR (20/23). (C) A 69-year-old woman, preoperative BCVA: 0.63 logMAR (20/85); postoperative BCVA: 0.22 logMAR (20/33). (D) A 71-year-old woman, preoperative BCVA: 0.45 logMAR (20/56); postoperative BCVA: 0.09 logMAR (20/24).

Fig. 5.

Representative OCT scans of a 69-year-old woman that underwent vitrectomy with CP of the ILM for VMT. (A) Preoperative appearances, BCVA: 0.82 logMAR (20/132); (B) two months after surgery, BCVA: 0.52 logMAR (20/66); (C) six months after surgery, BCVA: 0.52 logMAR (20/66). Nicks and dimples in the inner retinal layers can be seen extending over the center of the macula (red arrows); (D) 12 months after surgery, BCVA: 0.52 logMAR (20/66). Interestingly, the fovea shows progressive thinning over time (yellow arrows).

Fig. 6.

Optical coherence tomography scans of a 67-year-old woman who underwent complete ILM peeling. During the ILM peeling, an iatrogenic FTMH formed intraoperatively. The ILM peeling procedure was enlarged, and the eye was filled with 20% sulfur hexafluoride. The patient was positioned face down for a week. Preoperatively (A), VMT syndrome was visible; 1-month postoperatively (B), the FTMH closed, and the BCVA improved from 0.39 logMAR (20/49) to 0.22 logMAR (20/33); and 1-year postoperatively (C), an evident reduction in the thickness of the central retinal layers was appreciable.

Fig. 7.

Optical coherence tomography scan of a 65-year-old male patient with a broad VMT with dehiscence of the fovea, which was treated with phacoemulsification of the lens and PPV with complete ILM peeling. (A) Preoperative OCT scan showing a partial posterior vitreous detachment temporal to the fovea and a posterior hyaloid attached nasally. (B) The OCT scan performed during the follow-up visit a week after the surgery showing a secondary FTMH. A second PPV was performed one month after the first operation. The area of ILM peeling was enlarged, and the eye was filled with 20% sulfur hexafluoride. The patient maintained a face-down position for seven days. The closure of the macular hole occurred after the first week after the second PPV. Preoperative BCVA was 0.55 logMAR (20/70); postoperatively, it was 0.39 logMAR (20/49) at the end of the follow-up period.