Epiretinal membranes (ERMs) have been described for more than 150 years. Currently, they are a common indication for vitreoretinal surgery. Recently, there has been an increasing trend to peel the internal limiting membrane (ILM). Although ILM peeling has generally been accepted as a fundamental step in macular hole repair, its current role in ERM remains controversial.
Proponents of ILM peeling argue that peeling of the ILM reduces the recurrence rate and facilitates a greater resolution of retinal folds. Opponents of ILM peeling show that the visual outcomes between eyes that undergo ILM peeling and those that do not have their ILM peeled are the same. Stripping of the ILM removes the Müller cell footplates, so it is reasonable to expect some Müller cell dysfunction. Adverse events such as eccentric paracentral macular holes, macular microscotomata, and retinal dimpling have been associated with ILM peeling.
Internal limiting membrane peeling does not improve the functional outcomes after ERM surgery. Internal limiting membrane peeling reduces ERM recurrences, but many recurrences are not clinically significant. It remains unclear what the long-term effects of ILM peeling are. We should err on the side of caution and avoid routine ILM peeling in primary idiopathic ERM cases and should reserve it for recurrent and high risk of recurrence cases.
Internal limiting membrane peeling remains a controversial maneuver during epiretinal membrane surgery. Proponents argue that internal limiting membrane peeling ensures complete removal of the epiretinal membrane and reduces the recurrence of epiretinal membrane. However, paracentral or eccentric macular holes, macular microscotomata, inner retinal dimpling, and electroretinogram abnormalities have all been associated with internal limiting membrane peeling.
Macula, Vitreous and Retina Associated of Costa Rica, San José, Costa Rica.
Reprint requests: Lihteh Wu, MD, Asociados de Macula Vitreo y Retina de Costa Rica, Primer Piso Torre Mercedes Paseo Colón, San José, Costa Rica 10102; e-mail: LW65@cornell.edu
Presented in part at the 20th Duke Advanced Vitreous Surgery Course, April 21, 2017, Durham, NC.
L. Wu has received lecture fees from Bayer Health, Quantel Medical, Novartis, and Heidelberg Engineering. A. Díaz-Valverde has no conflicting interests to disclose.