Macula Surgery MD: Macula surgery for removal of macular pucker

FIGURE 1 THE HUMAN EYE WITH MACULAR CENTER OF VISION MARKED BY ARROW ADJACENT TO THE OPTIC NERVE.

macular membrane

FIGURE 2 (A) ABNORMAL GLIAL CELL MEMBRANES (G) ATTACHED TO THE MACULAR SURFACE (I = ILM) BEFORE CONTRACTION (R = RETINA). ANALOGOUS TO A LINE OF MEN HOLDING A ROPE (B).

Macular pucker

FIGURE 3 ( C) EMP AFTER CONTRACTION TO PRODUCE MACULAR PUCKER. ANALOGOUS TO A LINE OF MEN SHORTENING A ROPE (D).

FILMS

FIGURES 4 & 5 CURRENT FORCEPS TECHNIQUE OF REMOVING EMP / ILM BY RECURRENT GRASPING AND PEELING.

EMP

fluidic internal limiting membrane separation

FIGURES 6 & 7 FILMS CANNULA™ INSERTED UNDER SCARRED RETINAL SURFACE LAYER. GRADUAL INJECTION OF CLEAR, VISCOUS FLUID SEPARATES EMP / ILM COMPLEX FOR SUBSEQUENT EASY REMOVAL FROM THE EYE BY FORCEPS.

Fluidic Internal Limiting Membrane Separation Technique

This surgical technique of removing the internal limiting membrane (ILM) for patients with a distorted macula (macular pucker) or macular hole was developed by surgeons and researchers Robert Morris, M.D., C. Douglas Witherspoon, MD, and Ferenc Kuhn, MD, Ph.D. of Retina Specialists of Alabama, LLC and the Helen Keller Foundation for Research and Education located in Birmingham, Alabama. Potentially less traumatic than other conventional methods, FILMS is one of the currently available techniques effective in restoring sight to patients with specific forms of retinal deterioration caused by macular surface membranes. Macular disease under the retina, commonly called age-related macular degeneration (ARMD) is not treatable by FILMS.

More than 2.5 million people in the United States over age 50 are thought to have some surface scarring or wrinkling of the macular center of vision, a pinhead sized spot of retinal tissue (figure 1). The macula is responsible for sharp detail vision, and color vision. Macula conditions, variously called macular pucker, cellophane maculopathy, and macular hole are caused by surface scarring (epimacular proliferation, EMP) which can cause loss of fine vision to the level of legal blindness.

FILMS cannula

Surgeons insert a microscopic needle about one-tenth of 1 millimeter -- called a FILMS cannula (C)-- between the wrinkled retinal surface (I) and the healthy nerve tissue (R) underneath. Sterile fluid is injected through the needle between the retina's layers (V), creating a "bubble" effect that detaches the abnormal scar tissue from the rest of the macula. The surgeons then remove the loose wrinkled retinal tissue safely and easily.

Wrinkling of the retinal tissue in the macular area occurs when cells which accumulate over a lifetime reproduce and settle on the surface of the macula where they contract (figures 2 a,b, 3 a,b). This wrinkling of the macula also causes a distortion of the thin inner surface layer of the retina called the internal limiting membrane (ILM). Surface forces related to EMP are also thought to play a role in forming macular holes.

Each year approximately 25,000 to 40,000 people undergo one of the most delicate surgical maneuvers performed on the human eye, macular surgery, to treat macular pucker or macular hole. This surgery is performed under an operating microscope with the insertion of a tiny light probe and microsurgical instruments into the eye. The procedure requires precise viewing and maximum light transmission.

The standard surgery for macular pucker or macular hole repair is accomplished by peeling away the EMP and/or ILM that is causing the distorted vision with microsurgical forceps (figures 4,5). It is a time-sensitive, delicate and difficult operation. Lengthy surgery can result in potential over exposure to operating light resulting in light toxicity damage to the retinal nerve tissue. Inadvertent mechanical injury to retinal nerve tissue is another potential risk, both of which may reduce hoped for visual return. Because of these risks, many retinal surgeons and patients choose to defer surgery until after a significant irreversible loss of vision has already occurred.

The FILMS technique, in some cases, allows surgeons to safely and quickly remove the abnormal macular tissue and the wrinkled internal membrane layer by gently lifting and separating them by fluid pressure, simultaneously smoothing the underlying distorted retinal layer (figures 6,7). The FILMS cannula, a special type of needle developed by Drs. Morris, Witherspoon and Kuhn, is inserted parallel to the neural retina layer beneath the ILM layer. In one step the ILM and EMP are lifted in a fast, simple, more consistent and complete method. Rather than attempting to tease and pull the EMP from the retinal surface a piece at a time with forceps, FILMS is one of the various surgical techniques employed by retinal surgeons that may potentially reduce the risk of surgery and encourage patients and eye doctors to consider surgical intervention before long term retinal nerve damage causes irreversible loss of sight. FILMS allows retinal surgeons to operate within the retina instead of on the retinal surface. Complications prohibiting good vision return or necessitating repeat operations are expected to diminish due to the inherent simplicity and ease of the FILMS procedure.

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