Does the Presence of an Epiretinal Membrane Alter the Cleavage Plane during Internal Limiting Membrane Peeling?

Chromovitrectomy and the Vitreoretinal Interface

“…As mentioned earlier, the presence of cellular debris may be the result of this specific growth pattern. This hypothesis is in accordance with a recent immunohistochemical study of retinal cell debris on the ILM that demonstrated anti-glial fibrillary acidic protein-positive retinal cell fragments in correlation with the presence of epiretinal membranes [18] . Using light microscopy, this study did not confirm any influence of TB, ICG, or BBG on the removal of large retinal cell fragments and entire cell bodies during ILM peeling.…”

“…Light-and electron-microscopic studies as well as immunohistochemical studies demonstrated retinal cell debris on the ILM which was assigned to glial cells and neuronal cell debris, in particular Müller cell end feet and cell fragments of the retinal nerve fiber layer [8,9,[13][14][15][16][17][18] . Even without the use of vital dyes to assist macular surgery, it has been suggested that the presence of cellular debris adherent to the retinal side of the ILM is somehow inevitable as the ILM cannot be removed from the retinal surface without disrupting the underlying Müller cells, as the ILM represents their basal lamina and is therefore intimately associated with their plasma membrane [19] .…”

Vital dyes increase the rigidity of the internal limiting membrane

“…34 It was suggested that this observation may be related to the increased rigidity of a multilayered structure such as an epimacular membrane compared with the bare ILM, and the presence of retinal debris was interpreted as the result of a mechanical trauma during peeling. 34 The presence of sub-ILM changes in terms of cellular fragments was confirmed by a recent study by Hiscott and colleagues 35 suggesting that the plane of separation during ILM peeling for epiretinal membrane surgery may be altered. They concluded that this alteration was not related to the use of the dye, but should be interpreted as a result of the ERM formation or of the ERM-inducing pathology such as the modulation of GFAP within Mü ller cells or the continuity between components of epimacular membranes and the retina through pores of the ILM, which may increase the adhesion forces between these cells and the ILM.…”

“…They concluded that this alteration was not related to the use of the dye, but should be interpreted as a result of the ERM formation or of the ERM-inducing pathology such as the modulation of GFAP within Mü ller cells or the continuity between components of epimacular membranes and the retina through pores of the ILM, which may increase the adhesion forces between these cells and the ILM. 35,36 In addition, one may hypothesize that an epiretinal membrane, which is peeled off along with the underlying ILM, is stiffer compared with the ILM alone as removed during macular hole surgery. However, when taking together the described cellular interactions and our observations of increased rigidity in the stained ILM, regardless which dye is used, it is quite comprehensible that there is an increased likelihood to alter the cleavage plane during vitreoretinal surgeries both for epimacular membranes and macular holes to the inner retinal layers, because the rigidity is altered either by the presence of epimacular tissue or by the use of certain vital dyes.…”

Is traction the cause or the effect?

“…In a recent analysis of a series of internal limiting membranes (ILM) excised from eyes with diabetic macular oedema, we demonstrated using immunohistology the presence of glial and neural tissue on retinal and vitreal surfaces of the ILM as a clear indication of proliferative changes at the vitreoretinal interface. In the case of diabetic macular oedema, abnormalities of the vitreoretinal interface could be both the cause and the effect [5] .…”