David F. Williams, MD, MBA, discussed the watchand- wait approach to vitreomacular adhesion and macular hole and the fact that with stage 1 macular hole, there is up to a 50% rate of spontaneous resolution. What about our patients, however, who may require surgical intervention?
We do not currently have a uniform approach to surgery for vitreomacular traction (VMT) syndrome with or without macular hole, nor for epiretinal membrane (ERM). In my opinion, it is advantageous to release the ERM tractional component by removing the internal limiting membrane (ILM). There are data showing how altered anatomy via ILM removal results in a significantly lower incidence of recurrent ERM, persistent traction, or recurrent macular hole.1-3 Ten years ago, I do not think that ILM removal would be considered in the setting of standard surgical ERM management.
I also advocate the use of intravitreal steroids in vitrectomy, not for staining of the vitreous, but for their direct pharmacologic properties. It is true that there has been controversy regarding the occurrence of secondary sequelae, such as glaucoma or cataract formation, but we have performed ongoing evaluations at Bascom Palmer Eye Institute with intravitreal steroids used during surgery and there is strong evidence to support that they modulate macular thickening particularly in the immediate postoperative period with minimal risk of secondary glaucoma.4
Combined Phaco/Vitrectomy Case
A man aged 66 years was referred to the Bascom Palmer Eye Institute Corneal Service by an outside physician. He presented with 20/200 vision that was disproportionate to his cataract. A brief look at the macula revealed dense ERM and VMT with metamorphopsia (Figure 1). The fellow eye had some drusen (Figure 2)but no other significant pathology.
In this setting, I am a proponent of combining cataract and vitrectomy surgery as vitrectomy alone would not recover best visual acuity and the patient would have to undergo cataract surgery at a later date to ensure the best visual acuity. Combined pars plana vitrectomy and phacoemulsification surgery is the norm for patients managed outside of the United States with retinal pathology requiring surgical intervention and concommitant significant lens opacity. These combined procedures are much less commonly performed in the United States but appear to be increasing in frequency with the shift to microincisional vitrectomy surgery and clear cornea torsional phacoemulsification.
In this case, first I made the sclerotomies, and inserted valved trocars (Alcon Laboratories Inc.) to stabilize the fluidics. I performed torsional phaco through a clear corneal wound and implanted a foldable intraocular lens, leaving the viscoelastic in the eye. I proceeded to core vitrectomy, peeling the hyaloid membrane by engaging it with the vitrector. I prefer to remove the hyaloid anterior to the equator but not all the way to the ora serrata. Using indocyanine green (ICG) as a staining agent, I peeled the ERM and the ILM. I peel the ERM first, because it is difficult to engage the ILM over the ERM.
Staining agents have revolutionized my approach to membrane peeling. When I was in training, the theory was that when you peeled the ERM, you never went back and peeled the ILM because intraretinal edema and striae from the ERM peel compromised visibility. With ICG, however, I can easily identify residual ILM and am able to engage the tissue for removal.
One week after surgery, some traumatic impact sites remain from the peel but the membrane is gone and the contour has improved. Eight months later, he is psuedophakic, his metamorphopsia has decreased, and his vision has improved to 20/30 (Figure 3), but he is incredibly unhappy. Why?
The reason for his dissatisfaction is that he continues to have some persistent metamorphopsia. One thing that I am seeing more frequently in my practice is that now that we have the ability to significantly improve visual acuity, patients are more focused on quality of vision, almost as they would with refractive surgery. I typically tell my patients to expect a 2/3-line improvement in visual acuity in a case such as that I have described. So in this case, I advised the patient that he would most likely be 20/50 after surgery and his vision is even better at 20/30. I am thrilled. He is unhappy. This is, in my opinion, a result of increased patient expectations and is simply a consequence of our success in managing patients' disease.
Considerations in Surgery for VMT
The complications that are associated with surgery for VMT include a potentially higher incidence of retinal breaks, both intraoperatively and postoperatively, 5 retinal detachments,6-11 and endophthalmitis.3-11 Additionally, there is a possibility of incomplete separation of the vitreous, ERM, or ILM, with the potential for vasoactive and vasoproliferative substances affecting retinal function, the possibility for development of fibrovascular membranes, and iatrogenic trauma to the retina. The risk of complications is higher in more complex cases, so this must also be considered.
I am a strong believer in the use of a staining agent to facilitate ILM removal. It is also my experience that the use of adjunct intravitreal triamcinolone during vitrectomy can enhance resolution of intraretinal edema. Further, in my opinion, a combined approach when visually significant cataract is present is better than having the patient undergo 2 separate procedures, and it is critical to stabilize the anterior segment prior to vitrectomy. Finally, optical coherence tomography has helped improve our understanding of which patients with VMT will benefit from surgery.
Timothy G. Murray, MD, MBA, FACS, is a Professor of Ophthalmology with a Secondary Appointment in Radiation Oncology at Bascom Palmer Eye Institute at the Miller School of Medicine of the University of Miami. Dr. Murray may be reached at +1 305 326 6166; or via email at firstname.lastname@example.org.
- Kwok AK, Lai TY, Yuen KS. Epiretinal membrane surgery with or without internal limiting membrane peeling. Clin Experiment Ophthalmol. 2005;33(4):379-85.
- Kwok AK, Lai TY, Li WW, Woo DC, Chan NR. Indocyanine green-assisted internal limiting membrane removal in epiretinal membrane surgery: a clinical and histologic study. Am J Ophthalmol. 2004;138(2):194-199.
- Mester V, Kuhn F. Internal limiting membrane removal in the management of full-thickness macular holes. Am J Ophthalmol. 2000;129(6):769-777.
- Parke III DW, Sisk RA, Houston SK, Murray TG. Glaucoma After Intravitreal Triamcinolone with Vitrectomy and Phacoemulsification. Clin Ophthalmol. 2012. In press.
- Chung SE, Kim KH, Kang SW. Retinal breaks associated with the induction of posterior vitreous detachment. Am J Ophthalmol. 2009;147(6):1012-1016.
- Mojana F, Cheng L, Bartsch DU, et al. The role of abnormal vitreomacular adhesion in age-related macular degeneration: spectral optical coherence tomography and surgical results. Am J Ophthalmol. 2008;146(2):218-227.
- Doft BH, Wisniewski SR, Kelsey SF, Groer-Fitzgerald S; Endophthalmitis Vitrectomy Study Group. Diabetes and postcataract extraction endophthalmitis. Curr Opin Ophthalmol. 2002;13(3):147-151.
- Doft BM, Kelsey SF, Wisniewski SR. Retinal detachment in the endophthalmitis vitrectomy study. Arch Ophthalmol. 2000;118(12):1661-1665.
- Wisniewski SR, Capone A, Kelsey SF, et al. Characteristics after cataract extraction or secondary lens implantation among patients screened for the Endophthalmitis Vitrectomy Study. Ophthalmology. 2000;107(7):1274-1282.
- Gupta OP, Weichel ED, Regillo CD, et al. Postoperative complications associated with 25- gauge pars plana vitrectomy. Ophthalmic Surg Lasers Imaging. 2007;38(4):270–275.
- Liu DT, Chan CK, Fan DS, Lam SW, Lam DS, Chan WM. Choroidal folds after 25 gauge transconjunctival sutureless vitrectomy. Eye. 2005;19(7):825–827.
- Scott IU, Flynn HW Jr, Dev S, et al. Endophthalmitis after 25-gauge and 20-gauge pars plana vitrectomy: incidence and outcomes. Retina. 2008;28(1):138–142.
- Kunimoto DY, Kaiser RS; Wills Eye Retina Service. Incidence of endophthalmitis after 20- and 25-gauge vitrectomy. Ophthalmology. 2007;114(12):2133–2137.
- Kaiser RS. Complications of sutureless vitrectomy and the findings of the Micro-Surgical Safety Task Force. Paper presented at: Retina Subspecialty Day, Annual Meeting of the American Academy of Ophthalmology; November 7-8, 2008; Atlanta, GA.