Forceps Removal
of the Retinal
Internal Limiting Membrane in Surgery for
Macular Hole and Macular Pucker
Video script for Key Hole & Apple Peel Surgical Removal of ILM
Retina Specialists of
Alabama, LLC
Apple Peel and Keyhole Videotape
awarded American Academy of Ophthalmology Annual Meeting
Dallas, Texas / October 22-25, 2000
BEST OF SHOW in educational category
Robert Morris,
M.D., C. Douglas Witherspoon, MD, Ferenc Kuhn, MD, Ph.D.
Terry J. Moore, MD, S. Wayne Taylor, MD, Suzanne Nelson, R.N.
HealthSouth
Medical Center - Birmingham, Alabama, USA
Abstract
Removal of the internal
limiting membrane/epimacular proliferation (ILM/EMP) complex is
now a proven method for successful closure of macular holes, and
an evolving part of macular pucker surgery. We present new techniques
for forceps ILM removal in these conditions.
Macular Holes
In 1997 we introduced
a technique we called ILM maculorhexis for treatment of macular
holes to minimize foveal traction. This video presents two new versions
of ILM maculorhexis - the Key Hole technique and the Apple
Peel technique.
Following complete vitrectomy
and indocyanine green staining of the ILM as described by Kim and
Clark for clear demonstration of the internal limiting membrane,
the desired technique is begun.
The stages in performing
Key Hole ILM removal are:
· Establish the surgical plane
by production of an initial ILM handle using the Morris/Witherspoon
ILM forceps.
· Expand the surgical plane
by creation of a vertical ILM strip from the arcade vessels to the
macular hole. (Figures 1a, b, c)
· Parafoveal ILM maculorhexis.
(Figures 2a, b, c)
· Peripheral ILM maculorhexis.
(Figures 3a, b, c)
The elastic neurosensory
retina is now free of the rigid internal limiting membrane/EMP complex,
promoting true and permanent macular hole closure. (See figure 4
at top)
The Apple Peel technique
produces a single long strip of removed ILM, eliminating multiple
forceps re-insertion steps otherwise required to remove ILM fragments
from the eye.
Again using the Morris/Witherspoon
ILM forceps, the internal limiting membrane is grasped in a parafoveal
location and removed.
A parafoveal ILM maculorhexis
is performed, intentionally evolving into subsequent rhexis maneuvers
of enlarging diameters.
Finally, the macula is
freed of all surface traction, producing a continuous ILM strip
for removal from the eye as a single specimen.
Macular Pucker
After complete vitrectomy
and careful injection of indocyanine green dye, followed by its
removal, the epimacular proliferation complex is gently peeled from
the macula in the traditional manner.
ICG dye is then re-injected
and removed. Finally, the remaining distorted internal limiting
membrane is removed as a second layer, completely freeing the neurosensory
macula from all tangential traction.
Acknowledgment
The
Authors are affiliated with
The Helen Keller Foundation
For Research and Education &
The University of Alabama at Birmingham
Department of Ophthalmology
Lanning Kline, MD, Chairman
Bibliography
1. Vitrectomy
in Terson's Syndrome: A report of 21 cases. Morris, R., Kuhn, F.,
Brown, S., Feist, R: Scientific paper 1990
American Academy of Ophthalmology.
2. Hemorrhagic Macular Cysts. Morris, R., Kuhn, F., Witherspoon,
C.D. Ophthalmology 1994:100:1.
3. Hemorrhagic Macular Cysts in Terson's Syndrome and its implications
for Macular Surgery. Morris, R., Kuhn, F., Witherspoon,
C.D, Mester, V., Dooner, J. In Wiedeman, P, Kohn,
L (eds): Macular and Retinal Diseases. Dev. Ophthalmol. Basel, Karger,
1997, vol. 29, pp. 44-54.
4. Internal Limiting Membrane (ILM) Maculorhexis for Traction Maculopathy.
Morris, R., Witherspoon, C., Kuhn, F., Priester,
B. VRST Vol 8 No. 4, Winter 1997.
5. Macular Hole: Membrane Dissection Techniques. Witherspoon, C.,
Morris, R. Kuhn, F., Nelson, S. 1999 Pre-Academy
Retina Meeting.
6. Traction Maculopathy - Vitreomacular Traction Syndrome, Cellophane
Maculopathy, Macular Pucker, Macular Hole. Morris,
R., Witherspoon, C., Kuhn, F., Nelson, S., Priester,
B., Mayne, R. In Retinology Today, In Memoriam of Klaus Heimann,
Krieglstein (eds). Chapter 17, pp. 83-88, April
2000.
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