Macular hole surgery can be performed using various techniques and technologies. According to John T. Thompson, MD, the available evidence supports always incorporating internal limiting membrane (ILM) peeling, staining of the ILM, and having a large gas bubble in the eye on the first postoperative day.
Achieving the latter also may allow for a shorter duration of prone positioning, said Dr. Thompson, assistant professor, Wilmer Eye Institute, Johns Hopkins University, and partner, Retina Specialists, Baltimore, MD.
Citing a Cochrane meta-analysis that included four randomized trials [Cornish, et al. Ophthalmology. 2014;121(3):649-655], Dr. Thompson said there is strong evidence that peeling the ILM improves the rate of macular hole closure.
“In that review, ILM peeling was associated with a significantly higher rate of both primary and final macular hole closure, with odds ratios of 9.27 and 3.99, respectively,” he reported.
Dr. Thompson observed that a stain should be used to assure complete ILM removal. Options include trypan blue 0.15% (MembraneBlue, DORC), Brilliant Blue G 0.025% (DORC), and indocyanine green (ICG, usually 0.1%). The approval status and commercial availability of these products varies in different countries. In the United States, Brilliant Blue G is available only from compounding pharmacies and ICG does not have an FDA-approved indication for ILM staining.
The three staining options also vary in their efficacy and safety, Dr. Thompson said.
“Trypan blue does not stain the ILM very well,” Dr. Thompson explained. “Brilliant Blue G stains the ILM better and has an excellent safety profile. ICG gives the best staining, but can cause retinal pigment epithelium toxicity and so needs to be used with some cautions.”
Triamcinolone also can be used as an aid for ILM peeling. It does not stain the ILM per se, but when dusted on the macula, it allows the surgeon to see where the ILM has been removed.