Vitrectomy with Epiretinal Membrane Peel for Left Eye
Proceed with 23-, 25-, or 27-gauge pars plana vitrectomy with both epiretinal membrane (ERM) and internal limiting membrane (ILM) peeling, as this approach provides superior anatomical outcomes with lower recurrence rates while maintaining equivalent visual improvement. 1
Surgical Technique
The procedure should follow this systematic approach:
- Remove core vitreous and induce posterior hyaloid detachment from the optic nerve and macula using aspiration, an illuminated pick, or forceps 1
- Separate vitreous from retinal surface extending anteriorly to at least the equator 1
- Visualize the ILM using vital dyes—brilliant blue, trypan blue, or off-label indocyanine green at very low concentrations to minimize retinal trauma while improving visualization 1
- Elevate membrane edge using forceps, microvitreoretinal blade, diamond-dusted silicone tip, loop, or needle 1
- Peel both ERM and ILM together or sequentially with intraocular forceps 1
- Examine peripheral retina thoroughly for breaks or detachment after membrane removal 1
- Use small air bubble to seal non-sutured sclerotomies; reserve fluid-gas exchange (C3F8 or SF6) only if full-thickness or deep lamellar hole is suspected 1
ILM Peeling Decision
Always peel the ILM along with the ERM. Five studies demonstrate that ILM peeling reduces ERM recurrence rates significantly (from 16.3% to 0% in one study), while a systematic review of 13 studies found no difference in visual acuity outcomes but superior anatomical success with ILM peeling 1. The discretionary recommendation reflects equivalent visual outcomes, but the anatomical benefit justifies routine ILM removal 1.
Expected Outcomes and Patient Counseling
Visual Results
- Average improvement of 2 lines or more on Snellen chart, though results are highly variable 1
- 10-20% of patients will have unchanged or worse vision postoperatively—this must be explicitly discussed preoperatively 1
- Metamorphopsia improves in most patients and may completely resolve, often providing satisfaction even without visual acuity gains 1
- Intact ellipsoid zone on preoperative OCT predicts better postoperative visual outcomes 1
Major Complications to Discuss
- Cataract progression occurs in the majority of phakic patients at variable rates; consider combined cataract surgery or staged approach 1
- Retinal breaks occur in approximately 1% with 23-gauge systems 1
- Retinal detachment occurs in 1-3.5% depending on gauge (lower with smaller gauge) 1
- Endophthalmitis risk is less than 0.05% 1
- IOP fluctuations may occur, particularly in glaucoma patients 1
Anesthesia Approach
Use monitored anesthesia care with local anesthesia as the standard approach; reserve general anesthesia for anxious or claustrophobic patients 1
Postoperative Management
Follow-up Schedule
- Postoperative day 1: Mandatory first examination 1
- 1-2 weeks postoperatively: Second examination unless complications arise 1
- Earlier visits required for: High or low IOP, wound leak, pain, worsening vision, or suspected retinal complications 1
Each Visit Must Include
- Interval history focusing on new symptoms 1
- IOP measurement 1
- Slit-lamp biomicroscopy of anterior segment and wound sites 1
- Indirect binocular ophthalmoscopy of peripheral retina 1
- Counseling on postoperative medications 1
- Education on retinal detachment warning signs (increased floaters, visual field loss, metamorphopsia worsening, decreased acuity) 1
- Gas precautions if intraocular gas was used 1
Critical Pitfalls to Avoid
- Do not skip ILM peeling despite the discretionary recommendation—the anatomical benefit of reduced recurrence outweighs the theoretical concern of inner retinal tissue loss 1
- Minimize excessive intraoperative light exposure to the macula during surgery 1
- Do not underestimate cataract progression risk in phakic patients—46% required cataract surgery within 1 year in one study 2
- Ensure meticulous peripheral vitreous examination after membrane removal to identify and treat any retinal breaks intraoperatively 1