Prophylactic Internal Limiting Membrane Peeling During Rhegmatogenous Retinal Detachment Surgery

Acta OphthalmologicaVolume 99, Issue 4 p. e619-e620 Letter to the EditorFree Access Prophylactic internal limiting membrane peeling during rhegmatogenous retinal detachment surgery Matthew R. Starr, Matthew R. Starr orcid.org/0000-0002-3021-5630 Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania, USASearch for more papers by this authorAnthony Obeid, Anthony Obeid Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania, USASearch for more papers by this authorXinxiao Gao, Xinxiao Gao Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania, USASearch for more papers by this authorEdwin H. Ryan, Edwin H. Ryan VitreoRetinal Surgery, Minneapolis, Minnesota, USASearch for more papers by this authorGaurav K. Shah, Gaurav K. Shah The Retina Institute, St. Louis, Missouri, USASearch for more papers by this authorClaire Ryan, Claire Ryan VitreoRetinal Surgery, Minneapolis, Minnesota, USASearch for more papers by this authorMalika L. Madhava, Malika L. Madhava Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania, USASearch for more papers by this authorSean M. Maloney, Sean M. Maloney Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania, USASearch for more papers by this authorAdam Z. Adika, Adam Z. Adika Lewis Katz School of Medicine at, Temple University, Philadelphia, Pennsylvania, USASearch for more papers by this authorKrishi V. Peddada, Krishi V. Peddada Department of Ophthalmology, Drexel University College of Medicine, Philadelphia, Pennsylvania, USASearch for more papers by this authorKareem Sioufi, Kareem Sioufi Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania, USASearch for more papers by this authorMichael Ammar, Michael Ammar Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania, USASearch for more papers by this authorLuv G. Patel, Luv G. Patel Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania, USASearch for more papers by this authorNora J. Forbes, Nora J. Forbes VitreoRetinal Surgery, Minneapolis, Minnesota, USASearch for more papers by this authorAntonio Capone Jr., Antonio Capone Jr. Oakland University William Beaumont School of Medicine, Royal Oak, Michigan, USASearch for more papers by this authorGeoffrey G. Emerson, Geoffrey G. Emerson The Retina Center, Minneapolis, Minnesota, USASearch for more papers by this authorDaniel P. Joseph, Daniel P. Joseph The Retina Institute, St. Louis, Missouri, USASearch for more papers by this authorDean Eliott, Dean Eliott Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USASearch for more papers by this authorCarl D. Regillo, Carl D. Regillo Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania, USASearch for more papers by this authorJason Hsu, Jason Hsu Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania, USASearch for more papers by this authorOmesh P. Gupta, Omesh P. Gupta Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania, USASearch for more papers by this authorYoshihiro Yonekawa, Corresponding Author Yoshihiro Yonekawa [email protected] orcid.org/0000-0002-6847-7169 Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania, USA Correspondence Yoshihiro Yonekawa, MD Mid Atlantic Retina Retina Service of Wills Eye Hospital 840 Walnut St. Suite 1020 Philadelphia, PA, 19107 USA Tel: 215 928 3095 Fax: 215 928 3484 Email: [email protected]Search for more papers by this authorFor the Primary Retinal Detachment Outcomes (PRO) Study Group, For the Primary Retinal Detachment Outcomes (PRO) Study GroupSearch for more papers by this author Matthew R. Starr, Matthew R. Starr orcid.org/0000-0002-3021-5630 Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania, USASearch for more papers by this authorAnthony Obeid, Anthony Obeid Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania, USASearch for more papers by this authorXinxiao Gao, Xinxiao Gao Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania, USASearch for more papers by this authorEdwin H. Ryan, Edwin H. Ryan VitreoRetinal Surgery, Minneapolis, Minnesota, USASearch for more papers by this authorGaurav K. Shah, Gaurav K. Shah The Retina Institute, St. Louis, Missouri, USASearch for more papers by this authorClaire Ryan, Claire Ryan VitreoRetinal Surgery, Minneapolis, Minnesota, USASearch for more papers by this authorMalika L. Madhava, Malika L. Madhava Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania, USASearch for more papers by this authorSean M. Maloney, Sean M. Maloney Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania, USASearch for more papers by this authorAdam Z. Adika, Adam Z. Adika Lewis Katz School of Medicine at, Temple University, Philadelphia, Pennsylvania, USASearch for more papers by this authorKrishi V. Peddada, Krishi V. Peddada Department of Ophthalmology, Drexel University College of Medicine, Philadelphia, Pennsylvania, USASearch for more papers by this authorKareem Sioufi, Kareem Sioufi Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania, USASearch for more papers by this authorMichael Ammar, Michael Ammar Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania, USASearch for more papers by this authorLuv G. Patel, Luv G. Patel Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania, USASearch for more papers by this authorNora J. Forbes, Nora J. Forbes VitreoRetinal Surgery, Minneapolis, Minnesota, USASearch for more papers by this authorAntonio Capone Jr., Antonio Capone Jr. Oakland University William Beaumont School of Medicine, Royal Oak, Michigan, USASearch for more papers by this authorGeoffrey G. Emerson, Geoffrey G. Emerson The Retina Center, Minneapolis, Minnesota, USASearch for more papers by this authorDaniel P. Joseph, Daniel P. Joseph The Retina Institute, St. Louis, Missouri, USASearch for more papers by this authorDean Eliott, Dean Eliott Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USASearch for more papers by this authorCarl D. Regillo, Carl D. Regillo Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania, USASearch for more papers by this authorJason Hsu, Jason Hsu Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania, USASearch for more papers by this authorOmesh P. Gupta, Omesh P. Gupta Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania, USASearch for more papers by this authorYoshihiro Yonekawa, Corresponding Author Yoshihiro Yonekawa [email protected] orcid.org/0000-0002-6847-7169 Wills Eye Hospital, Mid Atlantic Retina, Thomas Jefferson University, Philadelphia, Pennsylvania, USA Correspondence Yoshihiro Yonekawa, MD Mid Atlantic Retina Retina Service of Wills Eye Hospital 840 Walnut St. Suite 1020 Philadelphia, PA, 19107 USA Tel: 215 928 3095 Fax: 215 928 3484 Email: [email protected]Search for more papers by this authorFor the Primary Retinal Detachment Outcomes (PRO) Study Group, For the Primary Retinal Detachment Outcomes (PRO) Study GroupSearch for more papers by this author First published: 04 August 2020 https://doi.org/10.1111/aos.14560Citations: 1 Relevant Disclosures: Consultant for Alcon (DE, OG, YY), Grant support from Alcon (AC), Royalties from Alcon (EHR), Stockholder in Aldeyra Therapeutics (DE, CR), Consultant for Dutch Ophthalmic (DE), Scientific Advisory Board for Pykus Therapeutics (DE), Stockholder in Valiant and Glaukos (GGE), Consultant for Allergan and Regeneron (GKS), Grant support from Allergan and Regeneron (GKS). Funding: Phillips Eye Institute Foundation, VitreoRetinal Surgery Foundation AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Dear Editor In the setting of a rhegmatogenous retinal detachment (RRD), retinal pigment epithelial (RPE) cells are released into the vitreous cavity and thought to provoke formation of proliferative vitreoretinopathy (PVR) membranes and PVR-related epiretinal membranes (ERM) following RRD surgery using the internal limiting membrane (ILM) as a scaffold (Fallico et al., 2018). Previous studies have suggested that there may be a reduction in ERM formation following repair of RRDs with prophylactic intra-operative ILM peeling (Yannuzzi et al., 2018) and potential better single surgery success. However, a clear benefit in final visual acuity or surgical success has not been established (Bawankule et al., 2019). The purpose of this paper was to examine the postoperative outcomes of eyes without preoperative macular pathology undergoing primary RRD surgery with and without the use of prophylactic ILM peeling during pars plana vitrectomy (PPV), in a large multicenter study. We report a subgroup analysis from the Primary Retinal Detachment Outcomes (PRO) study, which has been previously described in detail (Ryan, in Press). For the current study, consecutive patients with primary RRD who underwent repair with either primary PPV or a combination of PPV and scleral buckling from 1 January 2015, through 31 December 2015, from 6 centres across the country were included in the analysis. Eyes that had preoperative ERM, PVR or macular hole were excluded, meaning that this study only examined patients who had prophylactic ILM peeling in primary RRD without any macular pathology that would bias towards ILM peeling for other reasons. The primary outcome was single surgery anatomic success with secondary outcomes of final postoperative visual acuity and the development of postoperative ERM formation. There were 1442 eyes that met the inclusion criteria, with 41 eyes (2.8%) undergoing concomitant ILM peeling at the time of RRD surgery. Comparing eyes that underwent ILM peeling during RRD surgery versus those that did not revealed no significant differences in concomitant SB surgery, number of retinal breaks, pre- and postoperative visual acuity, macular detachment status, number of secondary retinal surgeries, or in the development of postoperative ERM (Table 1). Eyes that underwent ILM peeling had a significantly higher single surgery success rate following primary RRD repair (95% vs 85%, p = 0.03). This was maintained on multivariate analysis controlling for preoperative macular status, surgeon identification and type of retinal detachment surgery (p = 0.02). One eye (2.4%) developed an ERM post-ILM peeling while 21 (1.5%) developed an ERM in the non-ILM peeling cohort (p = 0.47). Table 1. Baseline demographic, visual and anatomic outcomes between eyes with and without internal limiting membrane peeling during retinal detachment surgery ILM Peeled (n = 41) ILM Not Peeled (n = 1401) p value Mean age (years) 62 ± 12 62 ± 11 0.89 Female 12 (29%) 495 (35%) 0.50 Mean logmar baseline visual acuity (Snellen) 1.07 ± 0.99 (20/235) 1.07 ± 1.07 (20/235) 0.69 Mean logmar final visual acuity (Snellen) 0.38 ± 0.58 (20/48) 0.43 ± 0.58 (20/54) 0.62 p value <0.0001* <0.0001* Intra-operative dye use 30 (73%) 98 (7.0%) <0.0001* Eyes with preoperative macula off retinal detachments 24 (59%) 673 (49%) 0.51 Eyes with combined scleral buckle and PPV 20 (49%) 545 (39%) 0.20 Number of preoperative retinal breaks 1.3 ± 1.0 1.2 ± 1.0 .71 Single surgery success rate 95% 85% 0.03* Eyes with an ERM postoperatively 1 (2.4%) 21 (1.5%) 0.63 Number of secondary retina surgeries 3 (7.3%) 190 (15%) 0.39 Mean follow up (days) 384 ± 146 398 ± 160 0.62 ERM = epiretinal membrane; ILM = internal limiting membrane; PPV = pars plana vitrectomy. *Statistically significant. We report that eyes without preoperative macular pathology undergoing ILM peeling at the time of RRD repair had higher single surgery success rates. There were no differences in postoperative ERM formation or final visual acuity. There is thought that by peeling the ILM prophylactically during RRD repair, the residual posterior cortical gel is completely removed as well as the scaffold on which cellular proliferation may develop, which may limit posterior PVR formation and perhaps prevent recurrent detachments (Hisatomi et al., 2018). It is plausible that by removing the ILM only within the arcades may be sufficient to remove more of the posterior cortical gel in enough high-risk eyes, or those with vitreoschisis, and prevent posterior PVR from applying traction on the peripheral retina. As with any surgical study with numerous different surgeons, a number of intra-operative factors cannot be accounted for that certainly could bias the results, such as the area of the ILM peel, dyes used to stain the ILM and different techniques for ILM peeling. Still, we report a significantly higher single surgery success rate in eyes that underwent peeling of the ILM during RRD surgery. Despite this anatomic success, there were no differences in final visual acuity or postoperative ERM formation between eyes with and without concomitant ILM peeling during RRD repair. References Bawankule PK, Narnaware SH, Raje DV & Chakraborty M (2019): Internal limiting membrane peel: Does it change the success rate of primary vitrectomy without belt buckle in rhegmatogenous retinal detachments? Indian J Ophthalmol 67: 1448– 1454. Fallico M, Russo A, Longo A et al. (2018): Internal limiting membrane peeling versus no peeling during primary vitrectomy for rhegmatogenous retinal detachment: A systematic review and meta-analysis. PLoS One 13: e0201010. Hisatomi T, Tachibana T, Notomi S et al. (2018): Internal limiting membrane peeling–dependent retinal structural changes after vitrectomy in rhegmatogenous retinal detachment. Retina 38(3): 471– 479. Ryan EH, Joseph DP, Ryan CM et al. (2020): Primary Retinal Detachment Outcomes Study: Methodology and Overall Outcomes—Primary Retinal Detachment Outcomes Study Report Number 1. Ophthalmology Retina. http://dx.doi.org/10.1016/j.oret.2020.02.014. Yannuzzi NA, Callaway NF, Sridhar J & Smiddy WE (2018): Internal limiting membrane peeling during pars plana vitrectomy for rhegmatogenous retinal detachment. Retina 38(10): 2081– 2087. https://doi.org/10.1097/IAE.0000000000002248. Citing Literature Volume99, Issue4June 2021Pages e619-e620 ReferencesRelatedInformation