ILM Peeling

Retinal membranes are diseases of the interface area between the back of the vitreous and the central area of the retina, the macula; they are characterized by the appearance of a translucent “sheet” in this area, which pulls and folds the macula, thus affecting the retinal cells and causing specific symptoms.

What is ILM Peeling?

ILM peeling is a surgical technique commonly used today to treat various vitreoretinal disorders, including macular holes, macular puckers, epiretinal membranes, diabetic macular edema, retinal detachment, retinal vein occlusions, vitreomacular traction, optic pit maculopathy and Terson syndrome. ILM detachment eliminates any tangential traction around the edges of the hole, a process thought to contribute to macular hole formation. It also ensures the removal of any remnants of hyaloids or epiretinal membranes that might otherwise be missed. This gives the patient the best chance of surgical success.

The internal limiting membrane (ILM), serves as the interface between the vitreous body and the retinal nerve fiber layer. It has a fundamental role in retinal development, structure and function, although it is also a pathological component in various vitreoretinal disorders, especially macular holes. It is only the understanding of the evolution of idiopathic macular holes and the emergence of idiopathic macular hole surgery that has led to the exploration of the idea of adjuvant ILM peeling in the treatment of tractional maculopathies. Currently, ILM peeling is a commonly applied surgical technique among vitreoretinal surgeons because it has been found to increase the rate of successful macular hole closure and improve surgical outcomes in other vitreoretinal diseases.

The macula is the central area of the retina, which is responsible for providing vision with precision and the ability to focus. If the macula is damaged, the patient loses visual acuity, seeing distorted images, details or colors. Virtually all vision and spatial perception is affected. The epimacular membrane may grow spontaneously and affect the macula.

How do you know you need ILM Peeling surgery?

The decision to opt for the ILM Peeling can be made in several cases:

Macular hole – In macular hole repair surgery, success rates for hole closure have improved, largely due to ILM peeling. Cell proliferation on the ILM can induce tangential traction. ILM removal improves the tractional component and has been shown to achieve successful macular hole closure at an anatomical level. Data from retrospective studies and meta-analyses indicate that vitrectomy with ILM peeling results in higher closure rates and improves visual acuity than does vitrectomy without ILM. Given the lower reoperation rate, ILM peeling is a cost-effective maneuver in initial macular hole surgery. ILM peeling is particularly important when other variables limit closure rates, such as in large, chronic or traumatic holes.

ILM peeling can also be considered in case of:

  • Epiretinal membrane removal
  • Diabetic macular edema
  • Retinal vein occlusion
  • Retinal detachment

ILM peeling has also been reported to be effective in surgery for vitreomacular traction, maculopathy optic fossa and Terson’s syndrome.

Risk factors can be: old age, vitreous detachment, history of epimacular membrane in the other eye. The population segment with the highest incidence is people over 60.

What are the symptoms that cause the ILM Peeling intervention?

  • decreased central vision, with difficulty reading, writing, distinguishing details, etc.
  • distorted vision – straight lines appear crooked, wavy or broken

In its advanced form, this membrane can cause complete destruction of cells in the central area, leading to what is called a “macular hole”, with complete loss of vision.

In most cases, the occurrence of epimacular membrane is idiopathic, i.e. its existence cannot be explained in relation to any other disease the patient may suffer from. In this case, the disorder occurs in healthy patients, without the presence of any other eye disease.

Most of the time, the sudden appearance of the epimacular membrane is caused by natural changes that occur in the vitreous body (part of the eye formed by a transparent gel in the center of the eye). These changes cause cells from the retina and other parts of the eye to enter the vitreous body. These cells eventually settle on the macula, where they can form a membrane.

In other cases, however, the epimacular membrane may have a secondary cause, i.e. it may be the result of a previous eye problem. These include:

  • Complication of retinal detachment surgery
  • Eye inflammation
  • Retinal blood vessel abnormalities
  • Eye injuries
  • Intraocular tumors
  • Degenerative retinal diseases
  • Retinal detachment

What does the ILM Peeling surgery involve?

ILM peeling is generally performed after standard pars plana vitrectomy with removal of the posterior haloid. ILM removal is technically difficult due to the transparency and the fact that the ILM is very thin. The use of an adjuvant dye for ILM staining facilitates its removal. Once this step is performed, the surgeon is able to remove the membrane using microsurgical forceps. If the patient has macular hole due to traction of the membrane, the surgical technique used is called inverted flap peeling.

What are the risk factors?

Risk factors can be: old age, vitreous detachment, history of epimacular membrane in the other eye. The population segment with the highest incidence is people over 60.

The epimacular membrane is treated surgically. The surgery consists of a vitrectomy, which removes the vitreous body. Once this step is performed, the surgeon is able to remove the membrane using microsurgical forceps. If the patient has a macular hole due to traction of the membrane, the surgical technique used is called inverted flap peeling.

What complications can occur after ILM Peeling surgery?

Minor complications, including focal retinitis, hemorrhages and oedema often resolve spontaneously. Direct mechanical trauma during peeling can also cause nerve fiber layer damage.

What are the specialist's recommendations after the ILM Peeling surgery?

  • treatment will be prescribed, which the patient will follow at home
  • touching the operated eye with a handkerchief or a dirty hand must be avoided
  • bathing is allowed, but be careful not to get water in the operated eye
  • physical effort should be avoided, and especially pressing or rubbing the operated eye
  • in case of any change in symptoms, the patient should see a doctor immediately
  • wear sunglasses during the day.
  • you may need to wear an eye patch or eye shield for a few days

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Text medically reviewed by Dr. Teodor Holhoș, Ophthalmic Surgeon
Written by Dr. Holhos Team
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