Virtual retinectomy: indocyanine green-assisted internal limiting membrane peeling as a surgical adjunct in repair of recurrent rhegmatogenous retinal detachment due to PVR

Figures & data

Figure 1 A schematic showing the theoretical mechanism of action. (A) posterior pole after staining, and (B) after ILM (internal limiting membrane)-rhexis, with vectors (arrows) of retinal relaxation after removal of ILM layer.

Table 1 Chronology of surgical procedures for each of the 14 cases

Pt	Surgical sequences
1	PPV, PPV, PPV/ILM-P
2	PPV, PPV, PPV/PPL/MP/SO, SOR/PPV/ILM-P, PPV, PPV/SO, SOR/SB/cryotherapy, PPV/MP/retinectomy, PPV/MP/SO, PPV/evacuate subretinal heme/SO, SOR
3	PPV, PPV/SB/SO, PPV/SO, PPV/SOR, PPV, PPV/ILM-P
4	SB/cryotherapy, external needle drainage/indirect laser, PPV, PPV/ILM-P
5	Laser retinopexy, laser demarcation, PPV, PPV/ILM-P
6	PPV, PPV, SB/PPV, PPV/ILM-P/SO
7	PPV/vitreous biopsy (PCR), PEIOL, PPV/ILM-P
8	SB/PPV, PPV/retinectomy/SO, SOR/PPV/ILM-P
9	PPV, PEIOL/PPV/ILM-P/SO, SOR, PPV, PPV/SO, SOR
10	SB, PPV, PEIOL, PPV/SO, SOR/PPV, laser demarcation, PPV/ILM-P
11	Laser retinopexy, PPV, PPV/SB/retinectomy/SO, PPV/ILM-P/SO
12	PPV/macular pucker, PPV, PPV/ILM-P
13	SB, PPV/SO, PPV/SOR/MP, PPV/ILM-P
14	PPV/evacuate subretinal heme, retinopexy, PPV/MP, PPV, SB/PPV/PPL/SO, SOR/PPV/ILM-P, PPV/SO, PPV/SOR

Abbreviations: ILM-P, internal limiting membrane peel; MP-PVR, membrane peel; PPV, pars plana vitrectomy; PPL, pars plana lensectomy; SB, scleral buckle; SO, silicone oil tamponade; SOR, silicone oil removal; PEIOL, phacoemulsification with intraocular lens implantation.

Table 2 Features of retinal detachment at time of surgery with ILM-peeling

Pt	Grade of PVR*	Location RD	Tamponade	Gauge
1	CP3, starfold	Inferior	C3F8, 12%	25
2	CP3, diffuse	Inferotemporal	SF6, 20%	25
3	B, diffuse posterior stiffness	Inferior	SF6, 20%	25
4	CA2, subretinal bands	Inferior	SF6, 20%	25
5	CP2, macular starfold	Temporal	SF6, 10%	20
6	B, diffuse posterior stiffness	Total	Silicone oil	25
7	CP3, diffuse stiffness and focal folds	Superotemporal	C3F8, 12%	25
8	CP4 diffuse folds, and CA3 anterior displacement	Inferior	C3F8, 12%	25
9	CP2 focal folds	Inferior	Silicone oil	25
10	CA3 anterior fibrosis/membranes	Inferior	C3F8, 12%	25
11	CA2 focal folds CP4 focal folds	Inferior	Silicone oil	20
12	CP3 focal folds	Superotemporal	C3F8, 10%	25
13	CP3 subretinal fibrosis inferior, and CA3 focal folds	Superior	SF6, 20%	20
14	B, diffuse stiffness	Temporal	SF6, 20%	20

Notes: Description of PVR location of retinal detachment, tamponade agent, and instrumentation gauge used.

* Machamer classification system.³⁵

Abbreviations: ILM, internal limiting membrane; PVR, proliferative vitreoretinopathy; RD, retinal detachment.

Figure 2 ILM peeling over detached macula using asymmetric 25-gauge end-grasping forceps. View the surgical video using this link: http://youtu.be/7KWk2Jyngrs.

Abbreviation: ILM, internal limiting membrane.

Table 3 Surgical features and clinical outcomes of study group

Pt	RD repairs before ILM-P (n)	RD repairs after ILM-P (n)	Previous SB?	Previous Si oil?	Retinectomy?	Postoperative VA	Factors affecting final VA
1	2	0	–	–	–	20/50−
2	3	6	–	Yes	Yes, after ILM-P	HM	Corneal opacification, s/p DSAEK
3	5	0	Yes	Yes	–	20/200	Aphakia
4	3	0	Yes	–	–	20/100+
5	1	0	–	–	–	20/30	Post PEIOL endophthalmitis
6	3	0	Yes	–	–	20/200	Retained silicone oil
7	1	0	–	–	–	20/50	Prior severe unknown posterior uveitis
8	2	0	Yes	Yes	Yes, before ILM-P	20/100
9	1	2	–	–	–	20/200	Developed full thickness macular hole postoperatively
10	4	0	Yes	Yes	–	20/60−
11	2	0	Yes	Yes	Yes, before ILM-P	20/400
12	1	0	–	–	–	20/80
13	3	0	Yes	Yes	–	20/200	Fuchs’/corneal edema
14	4	2	Yes	Yes	–	CF3′	History of submacular hemorrhage

Abbreviations: DSAEK, descemet’s stripping automated endothelial keratoplasty; HM, hand motion; ILM-P, internal limiting membrane peel; PEIOL, phacoemulsification with intraocular lens implantation; RD, retinal detachment; SB, scleral buckle; SO, silicone oil tamponade; VA, visual acuity.

MachemerRAabergTMFreemanHMIrvineARLeanJSMichelsRMAn updated classification of retinal detachment with proliferative vitreoretinopathyAm J Ophthalmol199111221591651867299

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