From the Guidelines
In cases of vitreomacular traction, peeling the inner limiting membrane (ILM) is strongly recommended during vitrectomy surgery to reduce the risk of recurrent epiretinal membrane formation and improve anatomical outcomes. This approach is supported by the most recent and highest quality study, which found that removing both the epiretinal membrane (ERM) and ILM led to a lower incidence of recurrent ERM compared to removing only the ERM 1. The study analyzed the results of seven studies that compared the outcomes of removing the ERM alone with removing both the ERM and ILM, and found that five of the studies favored peeling the ILM with the ERM.
Key Findings
- The study by Sandali et al. (2013) found that the recurrence rate of ERM was 8.6% in the non-ILM peel group and 2.6% in the ILM peel group 1.
- The study by Shimada et al. (2009) found that the recurrence rate of ERM was 16.3% in the ERM-only group and 0% in the ERM/ILM group 1.
- The use of dyes such as Indocyanine Green or Brilliant Blue G can help visualize the ILM and facilitate the peel, but the safety of these dyes remains somewhat controversial 1.
Surgical Technique
The procedure involves staining the ILM with dyes to improve visualization, followed by careful peeling using microforceps in a circular motion starting from the temporal macula and extending 1-2 disc diameters around the fovea. Potential complications include retinal trauma, photoreceptor damage, or paracentral scotomas, so the technique requires surgical expertise.
Biological Rationale
The biological rationale for ILM peeling is that it removes the scaffold for cell proliferation and contractile tissue formation, thereby reducing recurrence rates and improving anatomical outcomes. The decision to peel the ILM should be individualized based on the specific clinical presentation, and may not always be necessary for uncomplicated VMT cases with focal attachment. However, for cases with broader areas of traction, associated macular holes, or epiretinal membranes, ILM peeling is strongly advised.
From the Research
Vitreomacular Traction and Inner Limiting Membrane Peeling
- In cases with vitreomacular traction, the decision to peel the inner limiting membrane (ILM) is a crucial one, with various studies providing insights into the outcomes of this procedure 2, 3, 4, 5, 6.
- The study by 2 compared the sensitivity of the retina after complete ILM peeling versus foveal-sparing ILM peeling in vitrectomy for vitreomacular traction syndrome, finding that both techniques are safe and yield good anatomical and functional results.
- Another study 3 discussed the use of ILM peeling in vitreo-retinal surgery, highlighting its application in treating various retinal pathologies, including vitreomacular traction syndrome, and noting that further evidence is needed to guide its use.
Outcomes of Inner Limiting Membrane Peeling
- A study 4 assessed the efficacy of vitrectomy and ILM peeling in age-related macular degeneration resistant to anti-vascular endothelial growth factor therapy, with vitreomacular traction or epiretinal membrane, finding that this approach may be a useful therapeutic option.
- The review by 5 discussed the current rationale for ILM peeling in macular hole surgery, highlighting the improvements in closure rates and the prevention of postoperative reopening, but also noting the potential changes in retinal structure and function.
- A comparative study 6 investigated the long-term outcomes of pars plana vitrectomy with fovea-sparing ILM peeling and standard ILM peeling for myopic traction maculopathy, finding that the visual and anatomic improvements after vitrectomy with fovea-sparing ILM peeling may be comparable to those after vitrectomy with standard ILM peeling, with a lower risk of postoperative macular hole formation.
Considerations for Inner Limiting Membrane Peeling
- The decision to peel the ILM in cases with vitreomacular traction should be based on individual patient factors, including the severity of the condition and the potential risks and benefits of the procedure 2, 3, 4, 5, 6.
- The technique used for ILM peeling, such as foveal-sparing or complete peeling, may also impact the outcomes, with some studies suggesting that foveal-sparing peeling may be associated with better visual and anatomic results 2, 6.