- Email: [email protected]
Indocyanine green facilitates removal of epiretinal and internal limiting membranes in myopic eyes with retinal detachment
Surgical separation of the posterior hyaloid from the optic nerve head and the macula was induced by suction with the vitrectomy probe. One milliliter of indocyanine green dye (5.0 mg/ml) was injected over the posterior retina. The dye stained a discernable membrane, which was not as clearly detectable before. The membrane was readily engaged using a bent needle and an intraocular forceps. A continuous curvilinear tear was created around the macular hole, and the membrane was removed with perfect control over the area of the retina denuded from the membrane. We also studied five eyes of five patients with diffuse diabetic macular edema. No clinical evidence existed of an epiretinal membrane in any eye examined. A complete, standard three-port pars plana vitrectomy was performed. Intraoperatively, all eyes showed an attached posterior hyaloid. Separation of the posterior hyaloid from the optic nerve and posterior retina was initiated by suction with the vitrectomy probe and continued peripherally. One milliliter of indocyanine green dye (5.0 mg/ml) was injected over the posterior retina. The dye failed to stain a membranous structure. Peeling with the bent needle and intraocular forceps resulted in removal of a multilayered, soft-appearing preretinal tissue. Again, 1 ml of indocyanine green dye (5.0 mg/ml) was injected over the posterior retina. Now, the dye stained a clearly visible membrane that could be removed using the technique described before. Light and electron microscopy of all specimens from macular hole surgery and diabetic macular edema surgery revealed that the bare inner limiting membrane was the membrane that was stained ultramarine green by indocyanine green dye. Our study demonstrates that indocyanine green dye selectively stains the inner limiting membrane. The residual vitreous cortex can be easily distinguished from the inner limiting membrane by the lack of staining. Selective staining of the inner limiting membrane allows removal of the membrane more safely and effectively, with less risk of retinal damage. Furthermore, areas in which the membrane had already been removed can be clearly distinguished from areas of residual inner limiting membrane, and the appropriate size of the area to be removed can be determined more accurately. Moreover, indocyanine green dye allows a safe identification of residual vitreous cortex by the lack of staining. Especially in diabetic eyes, incomplete vitreoretinal separation is a common finding, and it carries the risk of cellular proliferation resulting in epiretinal membrane formation, traction on the retina, and deterioration of macular edema.1,5 Indocyanine green dye allows the identification of the residual vitreous cortex by negative staining. Staining of the inner limiting membrane after removal of the hyaloid provides more safety in complete removal of the vitreous cortex, even if the inner limiting membrane should be preserved.
2. 3. 4. 5.
Indocyanine Green Facilitates Removal of Epiretinal and Internal Limiting Membranes in Myopic Eyes With Retinal Detachment Shunji Kusaka, MD, Nobutsugu Hayashi, MD, Masahito Ohji, MD, Atsushi Hayashi, MD, Motohiro Kamei, MD, and Yasuo Tano, MD PURPOSE:
To describe the use of intravitreal indocyanine green as an aid to identifying epiretinal membranes and internal-limiting membranes during surgery for a retinal detachment resulting from a macular hole. METHODS: A 62-year-old man who had a retinal detachment resulting from a macular hole underwent vitrectomy. During the surgery, intravitreal indocyanine green was injected intravitreally. RESULTS: The internal-limiting membrane was stained green, but the epiretinal membrane was unstained. Because the epiretinal membrane and internal-limiting membrane were clearly identified, they could be completely removed. The clinical observations of the epiretinal membrane and internal-limiting membrane excised were confirmed by electron microscopy. Successful reattachment was obtained without damage to the retina. CONCLUSION: Removal of epiretinal membrane and internal-limiting membrane can be facilitated by using intravitreal indocyanine green during vitrectomy. We
Accepted for publication Oct 9, 2000. From the Department of Ophthalmology, Osaka University Medical School, Osaka, Japan (S.K., M.O., A.H., M.K., Y.T.), and the Department of Ophthalmology, Kochi Medical School, Kochi, Japan (N.H.). Supported by Grant-in-Aid 11771051 for Scientific Research from the Japanese Ministry of Education, Science, and Culture and by a grant for Research on Eye and Ear Science, Immunology, Allergy, and Organ Transplantation from the Ministry of Health and Welfare, Tokyo, Japan. Inquiries to Shunji Kusaka, MD, Department of Ophthalmology, E-7, Osaka University Medical School, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan; fax: ⫹81-6-6879-3458; e-mail: [email protected]
REFERENCES
1. Gandorfer A, Messmer EM, Ulbig MW, Kampik A. Resolution of diabetic macular edema after surgical removal of the
388
AMERICAN JOURNAL
posterior hyaloid and the inner limiting membrane. Retina 2000;20:126 –133. Park DW, Sipperley JO, Sneed SR, Dugel PU, Jacobsen J. Macular hole surgery with internal-limiting membrane peeling and intravitreous air. Ophthalmology 1999;106:1392–1397. Kadonosono K, Itoh N, Uchio E, Nakamura S, Ohno S. Staining of internal limiting membrane in macular hole surgery. Arch Ophthalmol 2000;118:1116 –1118. Gass JD. Reappraisal of biomicroscopic classification of stages of development of a macular hole. Am J Ophthalmol 1995; 119:752–759. Schwartz SD, Alexander R, Hiscott P, Gregor ZJ. Recognition of vitreoschisis in proliferative diabetic retinopathy. A useful landmark in vitrectomy for diabetic traction retinal detachment. Ophthalmology 1996;103:323–328.
OF
OPHTHALMOLOGY
MARCH 2001
FIGURE 2. Electron microscopy findings of the tissues removed during vitrectomy. (Left) Specimen removed from the intravitreal indocyanine green unstained area containing a fibrocellular epiretinal membrane and a fragment of internal-limiting membrane. The epiretinal membrane containing cellular component within collagenous matrix lines the smooth internal surface of segment of internal-limiting membrane. (Right) Ultrastructural appearance of a folded fragment of internal-limiting membrane removed from the intravitreal indocyanine green stained area shows the smooth surface internally and the irregular surface externally. No fibrocellular or cellular elements are present. Bars ⴝ 5 m.
recommend further studies to confirm the benefit of this technique. (Am J Ophthalmol 2001;131:388 –390. © 2001 by Elsevier Science Inc. All rights reserved.)
M
detachment, posterior staphyloma, and a macular hole. A pars plana vitrectomy was performed. After the mid-toposterior vitreous was removed, approximately 1 ml of
ACULAR HOLES ARE OFTEN FOUND IN HIGHLY MYO-
pic eyes, which, in turn, may lead to retinal detachments. A major problem in treating this type of detachment is the high incidence of redetachment resulting from a reopening of the macular hole.1–3 The pathogenesis of macular holes has not been determined, but tangential traction by epiretinal membranes is likely to play a critical role because successful removal of epiretinal membranes is associated with high reattachment rates.2,3 However, it is often difficult to remove epiretinal membranes completely from the detached retina because the epiretinal membrane is transparent and difficult to identify. In addition, the epiretinal membrane is sometimes firmly adherent to the detached retina.1–3 We report a technique to facilitate the identification and complete removal of epiretinal membranes. A 62-year-old man was referred for the treatment of a retinal detachment in his right eye. The best-corrected visual acuity was 20/400 with a ⫺11.0 diopter sphere RE. Biomicroscopic ophthalmoscopy revealed a total retinal VOL. 131, NO. 3
FIGURE 1. Intraoperative findings after intravitreal injection of indocyanine green. Internal-limiting membrane is stained green (arrowheads). In contrast, the epiretinal membrane is unstained but is outlined by the patchy staining retina.
BRIEF REPORTS
389
0.5% indocyanine green was injected into the vitreous cavity. After 10 seconds, the indocyanine green was washed out. A patchy green staining was observed (Figure 1) because the epiretinal membrane prevented the underlying internal-limiting membrane and retina from being stained while the internal-limiting membrane was stained in regions not covered by epiretinal membranes. The surface of the retina was detected using vitreous microforceps. Indocyanine green unstained, semitranslucent tissues and the indocyanine green stained, thin membrane-like tissues were removed from the retinal surface overlying the posterior staphyloma. These tissues were identified as complexes of epiretinal membranes and internal-limiting membranes and only internal-limiting membranes, respectively, by electron microscopy (Figure 2). Because the indocyanine green unstained area where these tissues had been removed was clearly identifiable from the greenstained internal-limiting membrane, the complete removal of the epiretinal membranes and internal-limiting membranes was easily accomplished. Fluid–air exchange was then performed followed by 14% perfluoropropane injection. The retina has remained attached, and the best-corrected visual acuity has improved to 20/200. We have applied this technique to three other similar cases with similar intraoperative and electron microscopy findings and clinical course. Indocyanine green has been used to dye internallimiting membranes during vitrectomy for idiopathic macular hole (Kim and Clark, unpublished data, 1999). It was reported that internal-limiting membranes are stained by indocyanine green, but epiretinal membranes are not (F. Shiraga, unpublished data, 2000), which is in good agreement with our findings. Although epiretinal membranes are not stained by indocyanine green, they are easily identified by detecting the surface of the nonstained retina adjacent to the stained retina. Thus, surgeons can avoid needless trauma to the retina caused by repeatedly probing the retina with membrane picks or forceps. Removal of the internal-limiting membrane may not be necessary for obtaining reattachment in some cases; however, its removal further assures the complete removal of the tangential traction on the retina and an improvement in the reattachment rate. Randomized clinical trials and longterm follow-up are necessary to confirm the efficacy and usefulness of this technique. For the present, we recommend using indocyanine green to facilitate the complete removal of epiretinal membranes.
macular holes in highly myopic eyes with retinal detachments. Retina 1997;17:2– 6. 3. Oshima Y, Ikuno Y, Motokura M, Nakae K, Tano Y. Complete epiretinal membrane separation in highly myopic eyes with retinal detachment resulting from a macular hole. Am J Ophthalmol 1998;126:669 – 676.
Macular Translocation for Subfoveal Choroidal Neovascularization in Angioid Streaks Daniel B. Roth, MD, Marc Estafanous, MD, and Hilel Lewis, MD PURPOSE:
To report a case of visual improvement after macular translocation performed for a subfoveal choroidal neovascular membrane in a patient with pseudoxanthoma elasticum and angioid streaks. METHODS: The fovea was translocated inferiorly by scleral imbrication, intentional retinal detachment with a small posterior retinotomy, and partial fluid–air exchange. The choroidal neovascular membrane was photocoagulated 1 week later. RESULTS: The visual acuity of the patient improved from 20/125 to 20/40. The center of the foveal avascular zone was moved inferiorly 844 m. The choroidal neovascular membrane was extrafoveal after translocation and was treated with laser photocoagulation. CONCLUSION: Macular translocation may be considered in the management of subfoveal choroidal neovascular membrane in patients with pseudoxanthoma elasticum and angioid streaks. (Am J Ophthalmol 2001;131: 390 –392. © 2001 by Elsevier Science Inc. All rights reserved.)
P
SEUDOXANTHOMA ELASTICUM IS A DISEASE CHARAC-
terized by calcification and fracture of elastic fibers throughout the body.1 Angioid streaks are estimated to be present in over 80% of pseudoxanthoma elasticum patients. Visual loss secondary to subfoveal choroidal neovascularization in patients with angioid streaks is significant, with most patients becoming legally blind by the age of 50.1 Several treatments have been attempted, including laser photocoagulation of the angioid streaks2 and submacular surgery.3 Macular translocation has also been performed on one patient with angioid streaks; however, the origin of the streaks was not determined.4 Visual acuity improved in this
REFERENCES Accepted for publication Sep 26, 2000. From the Cole Eye Institute, The Cleveland Clinic Foundation, Cleveland, Ohio. Inquiries to Hilel Lewis, MD, Cole Eye Institute, The Cleveland Clinic Foundation, 9500 Euclid Av./i30, Cleveland, Ohio 44195; fax: (216) 445-7654; e-mail: [email protected]
1. Stirpe M, Michels RG. Retinal detachment in highly myopic eyes due to macular holes and epiretinal traction. Retina 1990;10:113–114. 2. Seike C, Kusaka S, Sakagami K, Ohashi Y. Re-opening of
390
AMERICAN JOURNAL
OF
OPHTHALMOLOGY
MARCH 2001
2. 3. 4. 5.
Indocyanine Green Facilitates Removal of Epiretinal and Internal Limiting Membranes in Myopic Eyes With Retinal Detachment Shunji Kusaka, MD, Nobutsugu Hayashi, MD, Masahito Ohji, MD, Atsushi Hayashi, MD, Motohiro Kamei, MD, and Yasuo Tano, MD PURPOSE:
To describe the use of intravitreal indocyanine green as an aid to identifying epiretinal membranes and internal-limiting membranes during surgery for a retinal detachment resulting from a macular hole. METHODS: A 62-year-old man who had a retinal detachment resulting from a macular hole underwent vitrectomy. During the surgery, intravitreal indocyanine green was injected intravitreally. RESULTS: The internal-limiting membrane was stained green, but the epiretinal membrane was unstained. Because the epiretinal membrane and internal-limiting membrane were clearly identified, they could be completely removed. The clinical observations of the epiretinal membrane and internal-limiting membrane excised were confirmed by electron microscopy. Successful reattachment was obtained without damage to the retina. CONCLUSION: Removal of epiretinal membrane and internal-limiting membrane can be facilitated by using intravitreal indocyanine green during vitrectomy. We
Accepted for publication Oct 9, 2000. From the Department of Ophthalmology, Osaka University Medical School, Osaka, Japan (S.K., M.O., A.H., M.K., Y.T.), and the Department of Ophthalmology, Kochi Medical School, Kochi, Japan (N.H.). Supported by Grant-in-Aid 11771051 for Scientific Research from the Japanese Ministry of Education, Science, and Culture and by a grant for Research on Eye and Ear Science, Immunology, Allergy, and Organ Transplantation from the Ministry of Health and Welfare, Tokyo, Japan. Inquiries to Shunji Kusaka, MD, Department of Ophthalmology, E-7, Osaka University Medical School, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan; fax: ⫹81-6-6879-3458; e-mail: [email protected]
REFERENCES
1. Gandorfer A, Messmer EM, Ulbig MW, Kampik A. Resolution of diabetic macular edema after surgical removal of the
388
AMERICAN JOURNAL
posterior hyaloid and the inner limiting membrane. Retina 2000;20:126 –133. Park DW, Sipperley JO, Sneed SR, Dugel PU, Jacobsen J. Macular hole surgery with internal-limiting membrane peeling and intravitreous air. Ophthalmology 1999;106:1392–1397. Kadonosono K, Itoh N, Uchio E, Nakamura S, Ohno S. Staining of internal limiting membrane in macular hole surgery. Arch Ophthalmol 2000;118:1116 –1118. Gass JD. Reappraisal of biomicroscopic classification of stages of development of a macular hole. Am J Ophthalmol 1995; 119:752–759. Schwartz SD, Alexander R, Hiscott P, Gregor ZJ. Recognition of vitreoschisis in proliferative diabetic retinopathy. A useful landmark in vitrectomy for diabetic traction retinal detachment. Ophthalmology 1996;103:323–328.
OF
OPHTHALMOLOGY
MARCH 2001
FIGURE 2. Electron microscopy findings of the tissues removed during vitrectomy. (Left) Specimen removed from the intravitreal indocyanine green unstained area containing a fibrocellular epiretinal membrane and a fragment of internal-limiting membrane. The epiretinal membrane containing cellular component within collagenous matrix lines the smooth internal surface of segment of internal-limiting membrane. (Right) Ultrastructural appearance of a folded fragment of internal-limiting membrane removed from the intravitreal indocyanine green stained area shows the smooth surface internally and the irregular surface externally. No fibrocellular or cellular elements are present. Bars ⴝ 5 m.
recommend further studies to confirm the benefit of this technique. (Am J Ophthalmol 2001;131:388 –390. © 2001 by Elsevier Science Inc. All rights reserved.)
M
detachment, posterior staphyloma, and a macular hole. A pars plana vitrectomy was performed. After the mid-toposterior vitreous was removed, approximately 1 ml of
ACULAR HOLES ARE OFTEN FOUND IN HIGHLY MYO-
pic eyes, which, in turn, may lead to retinal detachments. A major problem in treating this type of detachment is the high incidence of redetachment resulting from a reopening of the macular hole.1–3 The pathogenesis of macular holes has not been determined, but tangential traction by epiretinal membranes is likely to play a critical role because successful removal of epiretinal membranes is associated with high reattachment rates.2,3 However, it is often difficult to remove epiretinal membranes completely from the detached retina because the epiretinal membrane is transparent and difficult to identify. In addition, the epiretinal membrane is sometimes firmly adherent to the detached retina.1–3 We report a technique to facilitate the identification and complete removal of epiretinal membranes. A 62-year-old man was referred for the treatment of a retinal detachment in his right eye. The best-corrected visual acuity was 20/400 with a ⫺11.0 diopter sphere RE. Biomicroscopic ophthalmoscopy revealed a total retinal VOL. 131, NO. 3
FIGURE 1. Intraoperative findings after intravitreal injection of indocyanine green. Internal-limiting membrane is stained green (arrowheads). In contrast, the epiretinal membrane is unstained but is outlined by the patchy staining retina.
BRIEF REPORTS
389
0.5% indocyanine green was injected into the vitreous cavity. After 10 seconds, the indocyanine green was washed out. A patchy green staining was observed (Figure 1) because the epiretinal membrane prevented the underlying internal-limiting membrane and retina from being stained while the internal-limiting membrane was stained in regions not covered by epiretinal membranes. The surface of the retina was detected using vitreous microforceps. Indocyanine green unstained, semitranslucent tissues and the indocyanine green stained, thin membrane-like tissues were removed from the retinal surface overlying the posterior staphyloma. These tissues were identified as complexes of epiretinal membranes and internal-limiting membranes and only internal-limiting membranes, respectively, by electron microscopy (Figure 2). Because the indocyanine green unstained area where these tissues had been removed was clearly identifiable from the greenstained internal-limiting membrane, the complete removal of the epiretinal membranes and internal-limiting membranes was easily accomplished. Fluid–air exchange was then performed followed by 14% perfluoropropane injection. The retina has remained attached, and the best-corrected visual acuity has improved to 20/200. We have applied this technique to three other similar cases with similar intraoperative and electron microscopy findings and clinical course. Indocyanine green has been used to dye internallimiting membranes during vitrectomy for idiopathic macular hole (Kim and Clark, unpublished data, 1999). It was reported that internal-limiting membranes are stained by indocyanine green, but epiretinal membranes are not (F. Shiraga, unpublished data, 2000), which is in good agreement with our findings. Although epiretinal membranes are not stained by indocyanine green, they are easily identified by detecting the surface of the nonstained retina adjacent to the stained retina. Thus, surgeons can avoid needless trauma to the retina caused by repeatedly probing the retina with membrane picks or forceps. Removal of the internal-limiting membrane may not be necessary for obtaining reattachment in some cases; however, its removal further assures the complete removal of the tangential traction on the retina and an improvement in the reattachment rate. Randomized clinical trials and longterm follow-up are necessary to confirm the efficacy and usefulness of this technique. For the present, we recommend using indocyanine green to facilitate the complete removal of epiretinal membranes.
macular holes in highly myopic eyes with retinal detachments. Retina 1997;17:2– 6. 3. Oshima Y, Ikuno Y, Motokura M, Nakae K, Tano Y. Complete epiretinal membrane separation in highly myopic eyes with retinal detachment resulting from a macular hole. Am J Ophthalmol 1998;126:669 – 676.
Macular Translocation for Subfoveal Choroidal Neovascularization in Angioid Streaks Daniel B. Roth, MD, Marc Estafanous, MD, and Hilel Lewis, MD PURPOSE:
To report a case of visual improvement after macular translocation performed for a subfoveal choroidal neovascular membrane in a patient with pseudoxanthoma elasticum and angioid streaks. METHODS: The fovea was translocated inferiorly by scleral imbrication, intentional retinal detachment with a small posterior retinotomy, and partial fluid–air exchange. The choroidal neovascular membrane was photocoagulated 1 week later. RESULTS: The visual acuity of the patient improved from 20/125 to 20/40. The center of the foveal avascular zone was moved inferiorly 844 m. The choroidal neovascular membrane was extrafoveal after translocation and was treated with laser photocoagulation. CONCLUSION: Macular translocation may be considered in the management of subfoveal choroidal neovascular membrane in patients with pseudoxanthoma elasticum and angioid streaks. (Am J Ophthalmol 2001;131: 390 –392. © 2001 by Elsevier Science Inc. All rights reserved.)
P
SEUDOXANTHOMA ELASTICUM IS A DISEASE CHARAC-
terized by calcification and fracture of elastic fibers throughout the body.1 Angioid streaks are estimated to be present in over 80% of pseudoxanthoma elasticum patients. Visual loss secondary to subfoveal choroidal neovascularization in patients with angioid streaks is significant, with most patients becoming legally blind by the age of 50.1 Several treatments have been attempted, including laser photocoagulation of the angioid streaks2 and submacular surgery.3 Macular translocation has also been performed on one patient with angioid streaks; however, the origin of the streaks was not determined.4 Visual acuity improved in this
REFERENCES Accepted for publication Sep 26, 2000. From the Cole Eye Institute, The Cleveland Clinic Foundation, Cleveland, Ohio. Inquiries to Hilel Lewis, MD, Cole Eye Institute, The Cleveland Clinic Foundation, 9500 Euclid Av./i30, Cleveland, Ohio 44195; fax: (216) 445-7654; e-mail: [email protected]
1. Stirpe M, Michels RG. Retinal detachment in highly myopic eyes due to macular holes and epiretinal traction. Retina 1990;10:113–114. 2. Seike C, Kusaka S, Sakagami K, Ohashi Y. Re-opening of
390
AMERICAN JOURNAL
OF
OPHTHALMOLOGY
MARCH 2001