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Anatomical and visual outcome of macular hole surgery with infracyanine green-assisted peeling of the internal limiting membrane, endodrainage, and silicone oil tamponade
better determine its usefulness. Because our study is small, it is difficult to draw broad conclusions about this treatment. However, our preliminary work in this area demonstrates some concerns we have with radial optic neurotomy and its outcomes. Until a prospective clinical trial is performed, this technique should be approached with intelligent caution, and careful individualized attention should be paid to the patient who is considering this surgery.
de Moere and associates did not address whether infracyanine green can cause similar photosensitization toxicity4 by creating a deeper cleavage plane. Moreover, it is unknown whether their patients have visual defects, because visual fields were not performed in this study. Second, all patients in the study received silicone oil tamponade instead of gas. We agree that silicone oil tamponade is useful, especially in patients who cannot comply with a face-down posture or who need to travel by air soon after surgery.3 However, the anatomic closure rate in this study is only comparable to those studies in which gas tamponade was used. Because an additional surgical procedure is necessary to remove the silicone oil, the routine use of silicone oil may be unnecessary, particularly given other potential side effects associated with silicone oil. Similarly, the use of perfluorocarbon liquid and endoscopic drainage may be unnecessary as well, especially in Stage II and III macular holes in which a higher success rate is anticipated without such procedures. Their use may still be beneficial in cases of large, persistent, or recurrent macular holes. Third, the authors performed endolaser at the vitreous base on every patient. This is unconventional, and we would like to learn details and rationale behind this procedure. We are inclined to limit the use of a laser around retinal breaks whenever possible. Excessive laser use can induce an appreciable inflammatory reaction that may cause complications such as postoperative epiretinal membrane formation. Although we commend Van de Moere and associates for their success in the macular hole surgeries using infracyanine green–assisted peeling of the ILM, endodrainage, and silicone oil tamponade, we hope the issues raised here can broaden the discussion and help spearhead the future direction for macular hole surgery.
JENNIFER S. WEIZER, MD S.S. STINNETT, DRPH S. FEKRAT, MD
Durham, North Carolina
REFERENCE
1. Weizer J, Stinnett S, Fekrat S. Radial optic neurotomy for central retinal vein occlusion. Am J Ophthalmol 2003;136: 814 –9.
Anatomical and Visual Outcome of Macular Hole Surgery With Infracyanine Green-assisted Peeling of the Internal Limiting Membrane, Endodrainage, and Silicone Oil Tamponade EDITOR: WE REFER TO THE ARTICLE BY VAN DE MOERE AND ASSOCI-
ates (Am J Ophthalmol 136:879 – 887, 2003) on macular hole surgery using infracyanine green–assisted peeling of internal limiting membrane, endodrainage, and silicone oil tamponade. Pars plana vitrectomy followed by internal tamponade by gas or oil is the key in macular hole surgeries.1,2 Various chemical or surgical adjuvants have been used to enhance the success rate of macular hole surgeries, and internal limiting membrane (ILM) peeling has become an important surgical adjuvant.3 The ease of ILM peeling is enhanced by the use of indocyanine green (ICG) stain.4 However, the toxicity of ICG is still an important issue.3,4 Van de Moere and associates concluded that infracyanine green–assisted removal of the retinal ILM appears to induce a high rate of anatomic closure with good visual outcome. There are, however, a few issues that we would like to mention. First, Van de Moere and associates claimed that infracyanine green is a less toxic stain but did not address sufficiently the safety of this new dye. The authors did not have histologic findings of the peeled ILM or epiretinal membrane (ERM). It has been reported that retinal tissue may be present in ILMs peeled with the use of ICG.3 Van 1162
AMERICAN JOURNAL
RITA GOPWANI, MRCSED (OPHTH) HUNTER K.L.YUEN, MRCSED (OPHTH) DENNIS S.C. LAM, MD, FRCOPHTH
Hong Kong, People’s Republic of China
REFERENCES
1. Kelly NE, Wendel RT. Vitreous surgery for idiopathic macular holes. Results of a pilot study. Arch Ophthalmol 1991;109: 654 –659. 2. Goldbaum MH, McCuen BW, Hanneken AM, et al. Silicone oil tamponade to seal macular holes without position restrictions. Ophthalmology 1998;105:2140 –2147. 3. Kwok AK, Li WW, Pang CP, et al. Indocyanine green staining and removal of internal limiting membrane in macular hole surgery: histology and outcome. Am J Ophthalmol 2001;132: 178 –183. 4. Yam GHF, Kwok AKH, Chan KP, et al. Effect of indocyanine green and illumination on gene expression in human retinal pigment epithelial cells. Invest Ophthalmol Vis Sci 2003;44: 370 –377. OF
OPHTHALMOLOGY
JUNE 2004
de Moere and associates did not address whether infracyanine green can cause similar photosensitization toxicity4 by creating a deeper cleavage plane. Moreover, it is unknown whether their patients have visual defects, because visual fields were not performed in this study. Second, all patients in the study received silicone oil tamponade instead of gas. We agree that silicone oil tamponade is useful, especially in patients who cannot comply with a face-down posture or who need to travel by air soon after surgery.3 However, the anatomic closure rate in this study is only comparable to those studies in which gas tamponade was used. Because an additional surgical procedure is necessary to remove the silicone oil, the routine use of silicone oil may be unnecessary, particularly given other potential side effects associated with silicone oil. Similarly, the use of perfluorocarbon liquid and endoscopic drainage may be unnecessary as well, especially in Stage II and III macular holes in which a higher success rate is anticipated without such procedures. Their use may still be beneficial in cases of large, persistent, or recurrent macular holes. Third, the authors performed endolaser at the vitreous base on every patient. This is unconventional, and we would like to learn details and rationale behind this procedure. We are inclined to limit the use of a laser around retinal breaks whenever possible. Excessive laser use can induce an appreciable inflammatory reaction that may cause complications such as postoperative epiretinal membrane formation. Although we commend Van de Moere and associates for their success in the macular hole surgeries using infracyanine green–assisted peeling of the ILM, endodrainage, and silicone oil tamponade, we hope the issues raised here can broaden the discussion and help spearhead the future direction for macular hole surgery.
JENNIFER S. WEIZER, MD S.S. STINNETT, DRPH S. FEKRAT, MD
Durham, North Carolina
REFERENCE
1. Weizer J, Stinnett S, Fekrat S. Radial optic neurotomy for central retinal vein occlusion. Am J Ophthalmol 2003;136: 814 –9.
Anatomical and Visual Outcome of Macular Hole Surgery With Infracyanine Green-assisted Peeling of the Internal Limiting Membrane, Endodrainage, and Silicone Oil Tamponade EDITOR: WE REFER TO THE ARTICLE BY VAN DE MOERE AND ASSOCI-
ates (Am J Ophthalmol 136:879 – 887, 2003) on macular hole surgery using infracyanine green–assisted peeling of internal limiting membrane, endodrainage, and silicone oil tamponade. Pars plana vitrectomy followed by internal tamponade by gas or oil is the key in macular hole surgeries.1,2 Various chemical or surgical adjuvants have been used to enhance the success rate of macular hole surgeries, and internal limiting membrane (ILM) peeling has become an important surgical adjuvant.3 The ease of ILM peeling is enhanced by the use of indocyanine green (ICG) stain.4 However, the toxicity of ICG is still an important issue.3,4 Van de Moere and associates concluded that infracyanine green–assisted removal of the retinal ILM appears to induce a high rate of anatomic closure with good visual outcome. There are, however, a few issues that we would like to mention. First, Van de Moere and associates claimed that infracyanine green is a less toxic stain but did not address sufficiently the safety of this new dye. The authors did not have histologic findings of the peeled ILM or epiretinal membrane (ERM). It has been reported that retinal tissue may be present in ILMs peeled with the use of ICG.3 Van 1162
AMERICAN JOURNAL
RITA GOPWANI, MRCSED (OPHTH) HUNTER K.L.YUEN, MRCSED (OPHTH) DENNIS S.C. LAM, MD, FRCOPHTH
Hong Kong, People’s Republic of China
REFERENCES
1. Kelly NE, Wendel RT. Vitreous surgery for idiopathic macular holes. Results of a pilot study. Arch Ophthalmol 1991;109: 654 –659. 2. Goldbaum MH, McCuen BW, Hanneken AM, et al. Silicone oil tamponade to seal macular holes without position restrictions. Ophthalmology 1998;105:2140 –2147. 3. Kwok AK, Li WW, Pang CP, et al. Indocyanine green staining and removal of internal limiting membrane in macular hole surgery: histology and outcome. Am J Ophthalmol 2001;132: 178 –183. 4. Yam GHF, Kwok AKH, Chan KP, et al. Effect of indocyanine green and illumination on gene expression in human retinal pigment epithelial cells. Invest Ophthalmol Vis Sci 2003;44: 370 –377. OF
OPHTHALMOLOGY
JUNE 2004