41. 25 g vitreomacular surgery

Steve T. Charles (Memphis)

Direction of Traction
EMM – Directed Inward & Tangential
Macular Hole – Directed Outward, Tangential and/or Circumferential
Vitreomacular Traction Syndrome – Directed Toward Vitreous Base (also called antero-posterior, perpendicular)

Epimacular Membrane Synonyms
Pre-Macular Fibrosis
• “epi” better than “pre”
• “gli”osis or RPE”osis”, not “fibr”- osis)
Macular Pucker (traction elevation, not just pucker)
Surface Wrinkling Retinopathy (where?)
Cellophane Maculopathy (what is cellophane?)

Cell Types in EMM Cases
Hypocellular Process
• Glial Cells
• – Modified Astrocytes
• RPE Cells
• – From Retinal Break, Cryo, Laser
• Inflammatory Cells
• – Uveitis

Pathogenesis of EMM
Roth & Foos
Posterior Vitreous Separation Causes Damage to Internal Limiting Membrane
Glial Cells Migrate to Retinal Surface
Hypocellular Contraction of Retinal Surface
Collagen Synthesis (late stabilization phase)
Should Not Be Called “Idiopathic”

History of Typical EMM Patient
Visual Loss & Metamorphopsia Over ~ One Month Period Followed By Stabilization of Vision
Not Progressive Loss of Vision Over Many Months (Alan Bird, Moorfields study & my personal experience)
Implication is That Observation Makes Little Sense as They Seldom Get Worse
Visual Prognosis
Recent Cases Have ~ Greater Visual Improvement (do not wait)
Macular Ischemia (DME, CRVO, BRVO, do FA to evaluate)
Long Duration RD Limits Visual Recovery (relative contraindication)
Better Pre-Op Vision Results in Better Post-Op Vision (no control over this factor).

Indications for EMM Surgery
Not Based on Rigid Visual Acuity Criteria
Symptoms & Visual Needs Are Critical
• Patient Should Make Decision Assuming Vision Will Remain Stable or Decrease Slightly If Not Operated
• Metamorphopsia is Important
• Dominant Eye Can Be Significant
• Examples:
• – 20/30-20/40 Pre-OP Va - Surgery Can Be Indicated If Patient Symptomatic & Well Informed and Surgeon Experienced
• – Asymptomatic & ~20/80 Needs No Surgery

Why Vitrectomy Is Needed
Reduction of Post-Operative Traction
Reduces Post-Op RD & Simplifies Rx
Patients Complain of Floaters, If No Vitrectomy
Membrane Peeling w/o Vitrectomy Did Not Reduce Cataracts or RD in Prospective, Consecutive Series of ~ 300 EMM Cases (Charles, 80’s)

My Current Technique
25 Gauge, Trans-Conjunctival, Sutureless PPV with Alcon Accurus System
Inside-Out, End-Grasping Forceps Peeling w/ Alcon 25G End-Grasping DSP ILM Forceps

Benefits of Inside-Out Forceps
Pics, Bent MVR Blades, and Many Types of Forceps Are Based on the Outdated Concept of Finding an “Edge” Which Damages the Retinal
Surface
Inside-Out, End-Grasping Forceps Membrane Peeling is Safer, and Requires No, Pics, Bent MVR Blades, Diamond Dusted Membrane
Scraper, or ICG
• ICG is Toxic and Enhances Photoxicity

Advantages of ILM Peeling
ILM Peeling Reduces Recurrence Rates (Anselm Kampnik)
Eliminates Striae, Hastening Visual Recovery & Reduced Distortion
Proves Complete Removal of Epiretinal Membrane and Residual Posterior Vitreous Cortex
20G Conformal Forceps
Radius Of Tip Conforms To The Radius Of Curvature Of The Retina
Fine End-Grasping Platform For Epimacular Membranes, Macular Holes/ILM, & PVR
Duroshell Coating For Reduced Friction, Wear, & Glare

Complications of EMM Surgery
This Data Based on Consecutive, Prospective, Single-Surgeon Series (SC) ~1400 Cases, (largest series)
Progression of Pre-Existing Nuclear Sclerosis, Up to 80 % Reported
Retinal Breaks & Detachment 1.5-5 % in Literature, my series has no posterior breaks, reported series less than 1 % with current 25G techniques
Recurrence of ERM, 1.6-8 % in Literature, ~1.0 % in my Series, Less w/ ILM Peeling (Anslem Kampnik)
Vitreous Hemorrhage - Rare
Endophthalmitis, Very Rare in Literature, None in My Series

Post-Op Nuclear Sclerosis
Probably Occurs Only If Pre-Op NS
Related to Increased Oxygen Tension in Vit Cavity {Post-PPV (Holekamp, Chang)
Potential Role of UV Light & IR from Operating Microscope & Endoilluminator
No Evidence That Infusion Fluid Causes Nuclear Sclerosis Progression, Author Uses BSS Plus
Simultaneous Endocapsular Lensectomy/IOL or Phaco/IOL Not Indicated for Most Cases
• Intra-Operative Visualization Worse If Phaco or PPL Before PPV and Membrane Peeling
• Refractive Outcomes Worse w/ Combined Procedures

EMM Summary
Best Technique: 25G, Sutureless PPV w/ DSP Forceps Inside-Out Membrane Peeling
• No ICG, Pics, Bent MVR, or Diamond Dusted Membrane Scraper Preferred Method
Vision Decreases Over One Month, Do Not Wait for Further Decrease, Make a Decision
Surgery Indicated If Pre-Op Vision 20/30 or Worse, Patient Symptomatic & Surgeon Experienced
MAC Anesthesia, Outpatient

Pathogenesis of Macular Holes
Probably from Contraction of the Prefoveal Vitreous Cortex, Hole Enlarges Because of Contraction of Myofibroblasts Attached to Clivus on
Internal Limiting Membrane
Probable Role of Mueller Cell Cones (JDM Gass, Arch Ophthalmol 1999 Jun;117(6):821-3
Apparent Posterior Vitreous Separation (Weiss ring) Does Not Prevent Macular Holes
Vitreous Cortex Attached to the Macula is Contiguous with Residual Vitreous Cortex Adherent to Optic Nerve in Some Stage 2 Holes Only
Not Avulsed Full Thickness Retina Caused By Adherence Coupled With Saccadic Force (older concept)

Types of Macular Holes
“Classic” Holes – (my term)
• Related to PVD, Vitreous Cortex (not idiopathic)
• Traction Cuff, Circular, Few If Any Striae
“Secondary” Holes (my term)
• 2° to Epiretinal Membranes - Less Frequent Cause of Macular Holes
• – Elliptical, Striae, No Traction Cuff
• Inflammatory (post-op CME, pars planitis, etc.)
• – No Traction Cuff
• – Surgery Not Indicated
• Vascular - NPDR/CRVO/BRVO
• – Surgery Indicated Only If Good Macular Perfusion on Fluorescein Angiography

What is the Cuff?
It Is Not the Cuff of Sub-Retinal Fluid, the Detached Area is Much Larger
• SLO Micro-Perimetry Demonstrates Much Larger Relative Scotoma, (Sjarda et al)
Cuff is Probably the Insertion Site of the Cortex Attached to the Margin of the Macular Hole
It Should Be Called the “Traction Cuff”

Keys to Better Prognosis
Smaller Holes (W. Freeman & Macular Hole Study Group)
Duration Determines Vision But Not Closure Rate If Size is Controlled For
• Roth DB; Smiddy WE; Feuer W – Chronic Macular Holes Have a Similar Anatomic Success Rate After Surgery, but a Poorer Visual
Prognosis Than Acute Holes
Face Down Compliance x ~5 Days Important
Peeling of Posterior Vitreous Cortex/ILM/ERM

Surgery to Prevent Macular Holes
First Done & Presented By Arthur Willis
First Published By Smiddy WE, Michels RG, Glaser BM, deBustros, S; AJO 1988, 105: 371-376
Controversial Issue

Prediction of Progression Impossible
30-50 % of Stage 1A, 1B Holes Spontaneously Abort (Charteris et al)
OCT, Ultrasound & Angiography Are of No Value In Predicting Progression From Partial to Full Thickness Hole
OCT is Invaluable to Differentiate Between Stage 1 A/B (pre-hole & Stage II (full thickness w/ vit txn, and Stage 3-4 w/ PVD) But Cannot
Predict Progression from Stage 1 to Stage 2
Not Other Eye Status (only ~6 % bilateral)

Macular Hole Prevention Surgery
Many Lamellar Holes & Macular Cysts Abort Due to PVD or Remain Stable
No Reliable Way to Predict Progression
Complications from Potentially Unnecessary Surgery is Major Issue
Proven Treatment Available, If Progression to Full Thickness Hole Occurs
Randomized, Multi-Center Clinical Trial Did Not Demonstrate Efficacy (DeBustros, Freeman, et al)
Conclusion: Do Not Operate Partial Thickness Holes
Macular Cysts Can Be Operated If Visual Complaints

Traumatic Macular Holes
Many Spontaneously Close in 2-6 Weeks
Operate Traumatic Holes, Only After ~Two Months Wait & Only If Submacular RPE & Optic Nerve Thought To Be Near Normal
Reasonable Anatomic and Success Rates in Several Reported Series

Surgery for Macular Hole
Kelly NE, Wendel RT Vitreous Surgery For Idiopathic Macular Holes Arch Ophth. 1991;109:654-659
Success Rates From 60 to 100 % Have Been Reported (90 % is reasonable)
• Reasons for Variability of Results Include: Hole Size, Cortex/ILM/ERM Peeling, Biologic Modifiers, Face Down Compliance, Air, SF6, C3F8,
or Silicone Oil, Study Design, Definition of Success, Follow-up Period, & Integrity of Investigators

Is PVD Creation Necessary?
Definition: Peeling from Optic Nerve & Mid-Peripheral Retina
Vitreous Attached to Optic Nerve is Rarely Attached to Macula
No Proof That RD Higher, If No PVD Made
Potential Complications of PVD Creation
• Optic Nerve Damage/Field Defects
• Retinal Detachment
My 4 Year Prospective Series Without PVD Creation Had 90 % Success Rate & Low RD Rate (~2 %)
In Recent Years I Have Resumed PVD Creation to Prevent Post-Op RD from Vitreous Contraction

Hole Closure Basics
SF6 & C3F8 Gases Better Than Air Alone
Face Down for ~7 Days
Peeling of Posterior Vitreous Cortex, ERM If Present, and ILM Improve Success Rates

ILM Elasticity
Wollensak et al on “Biomechanical significance of the human internal limiting lamina“ reported increased fragility of the retina after ILM
removal. There was less force required to elongate retina without ILM compared to retina with ILM. The mean force on the central retina
was reduced significantly by 53.6 % and the ultimate elongation by 27.03 % after ILM removal by laser. The ultimate elongation of the specimens
without ILM at the tear point was 3.05 ± 0.86 mm compared to 4.18 ± 0.56 mm in the macular controls ( with ILM)
Biomechanical behavior of the retina: by a short elastic phase and a remarkably broad plastic phase with irreversible deformation as shown
by the same authors

ICG Assisted ILM Peeling
Nicholas Engelbrecht, Jiong Freeman, Paul Sternberg, Thomas M. Aaberg, Sr.,Daniel F. Martin, Brian D Sippy
Retinal Pigment Epithelial Changes Following Macular Hole Surgery with Indocyanine Green Assisted Internal Limiting Membrane Peeling
Retrospective, Consecutive Study of 22 Cases
ICG (0.1 %), 1-2ml Applied Over Hole for 30-150 sec
Mean Pre-Operative Acuity 20/200
Mean Post-Operative acuity 20/400
Hole Closed in 86 %
Ten Eyes Had Unusual RPE Changes at Site of ICG Application

Kenalog Assisted PPV for Macular Hole Surgery
Increasing Anecdotal Evidence That Kenalog Reduces Hole Closure Rates
Anecdotal Evidence of Kenalog Incorporated in Closed Hole or Trapped in Subretinal Space

Rationale for Gas
Drying Effect Signals Modified Astrocytes to Repair Hole (Charles)
Surface (interfacial) Tension Effect Prevents Trans-Hole Fluid Flow (also known by the ill-defined term “tamponade”)
Eliminates Trans-Retinal Flow (uveal-scleral outflow, Charles ) and Therefore Reduces Retinal Edema (Tornambe hydration hypothesis)

Lateral Capillary Attraction Forces
Cause Immediate Closure (Vincent Reppucci, paper at Club Jules Gonin, Capetown, 2006)
Lateral Capillary Forces
Capillary forces occur when the contact of a body with a fluid phase boundary causes changes in the interfacial shape.
This force can appear around floating particles, semi-immersed objects, and particles confined in a liquid film.

Lateral Capillary Forces
These capillary forces can be large enough to cause the aggregation and ordering of small colloidal particles observed in many experiments.
Lateral Capillary Forces
Macular hole model is similar to immersion forces
Force generated is attractive, inversely exponential to distance
Lateral Capillary Forces Theory

Potential Biologic Modifiers
Autologous Serum
Autologous Whole Blood
Autologous Platelet Concentrates
Thrombin, Fibrin, etc.
TGF Beta
• Bovine - Very High Cost
• Recombinant - Minimal Effect, Mod Cost
• Autologous - Not Proven, Cost?

Problems With Biologic Modifiers
Sterile Endophthalmitis, Uveitis, PVR
Potential Contamination - Bacterial Endophthalmitis
Longer Operating Time, More Cost
Need to “Dry” Hole Can Dehydrate Retina (field defects, cataracts) and Prolong Surgery
Randomized Trials Showed No Effect of Serum (Freeman, et al) or Recombinant TGFB (Glaser)
I Do Not Use Biologic Modifiers
Most Surgeons Have Given Up Modifiers

Definition of Success
The Terms “Closure” & “Sealed” When Used in Retinal Detachment Repair Do Not Mean Margin-to-Margin Closure
Lateral Surface Tension Pull Macular Defect Back Together, This is Followed Glial Cells Healing
Reattachment of Retina Around Hole Causes Modest Visual Increase & Should Not Be Defined As Success or Closure
The Goal Is Reapproximation of the Hole Margins & Marked Visual Improvement

Face Down Compliance
Most Studies Demonstrate Better Outcomes With C3F8 or SF6 Than Air
Hole Closure Probably Occurs in <5 Days
I Changed from C3F8 to SF6 in mid-2006
Some Surgeons (Tornambe) State That Face Down Compliance Not Important
Most Surgeons & Author Believe That Full-Time Face Down Compliance for One Week Reduces PSC

Silicone Oil for Macular Holes
Brooks McCuen - 50 Cases, 75 % Success With One Procedure, 88 % With Two Procedures
• Vision Worse in Oil Group, 65 % Closure Rate With Single Procedure, 90 % With Two Procedures (McCuen, 54 eyes)
Air & Gas Have 73 NM/M Interfacial Tension, Silicone Oil Has 20 NM/M
• In Patients That Cannot Be Face Down Use C3F8 & Combined Phaco/IOL
• Severe Obesity, Severe Spinal Disease, Psychologic or Neurologic Disorders
Conclusion: Don’t Use Silicone Oil

Reopening of Macular Holes
Christmas NJ; Smiddy WE; Flynn HW Jr
• 390 Eyes
• 4.8 % Reopened
Other Series Have Reported a ~10 % Incidence of Reopening
My Series is < 2 %
Probably Dependent on Successful Peeling of Cortex/ILM/ERM
Post-Op FGX for Failed Surgery
Ohana E; Blumenkranz MS
• 13/15 Successful, Used Laser in Hole & Gas
Johnson RN; McDonald HR; Schatz H; Ai E, Ophthalmology 1998 Oct;105(10):1787-8, 17 eyes, 74 % success
Post-Op FGX for Failed Surgery is Probably Underutilized

Post-Op Retinal Detachment
Tabandeh H; Chaudhry NA; Smiddy WE
• 1.8 % of 438 eyes , 3.5 % in first 200 cases, 0.4 % in next 200 cases
Chang TS; McGill E; Hay DA; Ross WH; Maberley AL, Sibley LM; Ma PE; Potter MJ
• 326 patients, 13.2 % if no buckle compared with 5.9 % with buckle
Heier JS; Topping TM; Frederick AR Jr; Morley MG, Millay R; Pesavento RD
• 76 % of all breaks were located inferiorly
Akduman L; Del Priore LV; Kaplan HJ
• 6/73 eyes developed a post-op RD; inferior RD in all cases, 2 eyes with inferior retinal breaks had RD surgery, retinal breaks could not be
identified in the other 4 eyes; RD resolved without surgery if no breaks

Peripheral Field Defects
Retina Dehydration Caused by Dry Air From Air Pump & Long Procedures Driven By the Use of Biologic Modifiers & “Hole Drying” May Cause
Field Defects
• Ohji M; Nao-I N; Saito Y; Hayashi A; Tano Y
• Am J Ophthalmol 1999 Sep;128(3):396-7
• This Combined Retrospective & Prospective Series, Did Not Comment on Peeling Vitreous From Optic Nerve, Therefore Did Not Prove
Dehydration Hypothesis
Forceful Peeling of PVC from Optic Nerve is More Likely Cause in Most Cases

My Current Technique
25 Gauge, Trans-Conjunctival, Sutureless PPV with Alcon Accurus System
PVD Creation Without Forceful Peeling of Vitreous From Optic Nerve
Peel Cortex/ILM/ERM with 25G End-Grasping Alcon DSP Forceps
No pics, bent MVR blades, ICG, Kenalog, or diamond dusted membrane scrapers
SF6, Face Down for ~7 Days, 24 hours/day

Controversies
Should Stage 1 Holes Be Operated – No
Should PVC Be Peeled Off Mid-Peripheral Retina – Yes, to Reduce RD
Role of ILM, PVC, & ERM Peeling – Crucial
Is There a Role for Biologic Modifiers – No
ICG Staining of ILM – No, Toxicity
Is Face Down Compliance Necessary – Yes
Does Silicone Oil Work as Well as Gas – No
Size, Not Duration Determines Closure Rate

Edema Reduction Mechanisms
Elimination of Traction
• No Scientific Evidence That Traction on ILM/Retina Causes Edema
• Extensive Evidence That Macula Separation from RPE Pump Causes Edema, OCT Shows Subretinal Fluid in Most Cases
Reduction of VEGF (Charles)
Better Macular Oxygenation (Holekamp, Steffanson)

Indications for PPV for DME
Minimal or No Response to Focal Photocoagulation and Anti-VEGF Agents After ~2 Months
FA Evidence of Marked Leakage & Minimal Macular Ischemia
OCT Evidence of Vitreomacular Traction Is Definite Indication, Absence of Traction is Not a Contraindication
Clinical Evidence of Vitreomacular Traction Using Plano, Anti-Reflective Coated, Contact Lens Much Better Than 90D

DME Technique
Core Vitrectomy
Gentle PVD Creation (anterior not lateral suction at disk margin or forceps)
Peeling with Alcon 25G DSP Forceps (I use no pics, DDMS, or ICG)
Focal Laser to MA’s, IRMA, ERM Vascular Attachment Points

Indications for Submacular Surgery
Not AMD (CNV is under RPE)
Membranes Anterior to RPE
• Idiopathic, Some POHS, Myopic, Etc.
• Not Responsive to Anti-VEGF Therapy (intravitreal Avastin, Lucentis)
Operate Recent, But Stable “Membranes”
• Leakage Suppressed by Anti-VEGF Rx

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