Staining of Internal Limiting Membrane in Vitreomacular Surgery: A Simplified Technique

Irreversible Damage to the Fovea in Indocyanine Green-assisted Internal Limiting Membrane Peeling

“…Irrespective of our adherence to these guidelines, when injected onto the bare retina, ICG caused permanent damage to the fovea. Given the role of the ILM as a barrier at the vitreoretinal interface protecting the underlying neuroretinal tissue [6], injecting ICG dye without the ILM may cause direct damage to the retinal tissue. Therefore, direct injection of the ICG to confirm the presence of remnant ILM should be performed with caution.…”

Intravitreal Staining of the Internal Limiting Membrane Using Indocyanine Green in the Treatment of Macular Holes

“…The dried ICG powder, which contains iodine to increase its solubility, must be dissolved in water or a glucose/water solution prior to injection, as dilution in plane sodium chloride induces dye precipitation [10,11,12,13, 47, 77, 78]. Precipitation by dissolving ICG in a salt solution may be prevented by the use of a filter during the dye preparation [14].…”

“…In this approach, the intravitreal fluid (usually BSS) is left inside the vitreous cavity while the surgeon injects ICG. Those who advocate this technique state that the amount of ICG dye in contact to the retinal surface becomes much lower, because the ICG is immediately washed out by the fluid in the vitreous cavity after its injection [78]. The disadvantage of this method is the possible dispersion of the dye into the entire vitreous cavity, leading to unwanted staining of other intraocular tissues such as the lens.…”

“…While some authors proposed an immediate washout of ICG from the vitreous cavity, others reported incubation times of up to 5 min before removing it (table 1). Studies reporting a higher rate of complications (such as RPE changes or visual field defects) frequently used a long ICG incubation time [44, 65] In contrast, recent publications denying clinical toxic effects of ICG for macular hole surgery have proposed washing out the dye immediately or within a few seconds after injection [81, 78]. Another concern relates to ICG reinjections after ILM peeling on the retina.…”

“…(4) Direct injection toward the IMH should be avoided to prevent the dye flowing through the IMH and coming in contact with the RPE [78]. There are several means to prevent this: (a) protecting the hole itself by injecting viscoelastic or perfluorocarbon liquids (PFC) before injecting ICG towards the macula [86]; (b) dissolving the ICG in a viscoelastic substance, which may diminish the amount of ICG entering the macular holes, and (c) directing the infusion cannula away from the IMH itself.…”