Subscribe to Newsletter
Subspecialties Retina

A-peeling Approach?

Filippo Pacini, the Italian anatomist who discovered the internal limiting membrane (ILM) around 170 years ago, would probably be surprised by the amount of time we spend talking about this tissue. One frequently raised question is: does the ILM need to be removed, in all cases of macular holes? The short answer is, no. For the longer answer, we should ask three questions: is ILM peeling in all cases necessary? If it’s not necessary, does it improve the odds of success? And finally, is it safe?

We were able to close 60 to 90 percent of holes with just the removal of the posterior hyaloid.

First, the issue of necessity: the most important pathologic tractional force in most macular holes is vitreomacular traction. We know this because in the era prior to ILM peeling, we were able to close 60 to 90 percent of holes with just the removal of the posterior hyaloid. We can also use pharmacologic agents like ocriplasmin to close holes – in the MVI-TRUST study, this was effective in about 40 percent of cases (1). We can also get a successful closure using other methods that separate the macular posterior hyaloid and spare the ILM, such as placing an intraocular gas bubble in the office without vitrectomy.  With today’s modern OCT imaging technology, I believe we can now preoperatively or intraoperatively identify those cases that may only require posterior hyaloid removal, potentially sparring additional retinal dissection.

Second, I will concede that ILM peeling does improve the chance of closure (and lessen the chance of reopening) and now using ILM removal we are guaranteed closure in nearly 100 percent of cases. But this benefit comes at the price of potential risks; when we remove the ILM, we not only remove the footplates of Müller cells, but also nerve fibers and glial cells. Most studies find little difference in visual outcomes when comparing peeling versus no peeling, but the majority of these studies used non-standardized visual acuity measurements, and had limited follow-up. Additionally, vision is only one measure of central visual function. One microperimetry study found microscotomas and decreased sensitivities in patients who had undergone ILM peeling, but not in non-ILM peeled patients (2). Visual field defects are also more common with ILM peeling versus no ILM peeling for macular holes (3). And we’ve seen that ILM-peeled patients display a decreased b-wave response in multifocal electroretinograms (4).

Additionally, most surgeons (in the United States at least) use indocyanine green (ICG) for intravitreal staining of the ILM, which has demonstrated retinal toxicity (5). In meta-analysis, it has also been associated with lower post-surgical improvements in visual function than patients who underwent an ILM peel without ICG being used (6).

In summary, ILM peeling is not necessary in all cases, but does improve chances of closure – with the tradeoff of exposing your patient to all of the risks inherent to the ILM removal procedure. With today’s technology, we’re better placed than ever before to identify patients who may only need the posterior hyaloid removed. In my practice today, I still remove the ILM – but it is becoming clear that in some cases, less may be more.

Receive content, products, events as well as relevant industry updates from The Ophthalmologist and its sponsors.

When you click “Subscribe” we will email you a link, which you must click to verify the email address above and activate your subscription. If you do not receive this email, please contact us at [email protected].
If you wish to unsubscribe, you can update your preferences at any point.

  1. P Stalmans et al., “Enzymatic vitreolysis with ocriplasmin for vitreomacular traction and macular holes”, N Engl J Med, 367, 606–615 (2012). PMID: 22894573.
  2. R Tadayoni et al., “Decreased retinal sensitivity after internal limiting membrane peeling for macular hole surgery”, Br J Ophthalmol, 96, 1513–1516 (2012). PMID: 23077227.
  3. F Ando, “Anatomic and visual outcomes after indocyanine green-assisted peeling of the retinal internal limiting membrane in idiopathic macular hole surgery”, Am J Ophthalmol, 137, 609–614. PMID: 15059697.
  4. H Terasaki et al., “Focal macular ERGs in eyes after removal of macular ILM during macular hole surgery”, Invest Ophthalmol Vis Sci, 42, 229–234 (2001). PMID: 11133873.
  5. A Gandorfer et al., “Toxicity of indocyanine green in vitreoretinal surgery”, Dev Ophthalmol, 42, 43–68 (2008). PMID: 18535381.
  6. EB Rodrigues, CH Meyer, “Meta-analysis of chromovitrectomy with indocyanine green in macular hole surgery”, Ophthalmologica, 222, 123–129 (2008). PMID: 18303234.
About the Author
Dante Pieramici

Dante Pieramici is Co-Director of the California Retina Research Foundation, partner at California Retina Consultants, and Assistant Clinical Professor of Ophthalmology, Doheny Eye Center, California, USA.

Related Product Profiles
Uncover the Unique DNA of SPECTRALIS®

| Contributed by Heidelberg Engineering

Subspecialties Retina
ForeseeHome® – remote monitoring to help detect wet AMD earlier and improve outcomes

| Contributed by Notal Vision

Product Profiles

Access our product directory to see the latest products and services from our industry partners

Most Popular
Register to The Ophthalmologist

Register to access our FREE online portfolio, request the magazine in print and manage your preferences.

You will benefit from:
  • Unlimited access to ALL articles
  • News, interviews & opinions from leading industry experts
  • Receive print (and PDF) copies of The Ophthalmologist magazine



The Ophthalmologist website is intended solely for the eyes of healthcare professionals. Please confirm below: