Figure 1
Histological evaluation of internal limiting membrane (ILM) from
human eyes; A – Light microscopy showing the ILM (intense staining at
the folds). Note that this membrane is slightly stained along the entire
portion that it is not folded (arrows at the edges of the ILM); the dots
- background - are the millipore filter. (Hematoxilineosin. Original
magnification x 40); B – Electron Microscopy of a folded ILM (both “ILM
vitreous surfaces” are almost touching); note the mild amount of
cellular debris along the retinal surface - arrows. (13.000 x)
Figure 2
Electron microscopy of the ILM after peeling procedure with no use of
dyes. Despites the gentle maneuver during the surgery, a portion of the
nerve fiber layer/ganglion cells (inferior left) was peeled within the
ILM; this results in visual fields defects by clinical
evaluation
Figure 3
Peeling is facilitated because ICG produce an ILM stiffness and a
very good contrast to the retina
Figure 4
RPE changes after ILM peeling in macular hole surgery guided by
5mg/mL of indocyanine green; A - Fundus photography showing that
macular hole is sealed. However, pigmentary changes are observed
(arrow) and abnormal clinical aspect the previous macular hole
(arrowhead); B - Early phase of fluorescein angiogram showing
hypofluorescent image inferior to the previous macular hole (arrow)
and hyperfluorescent image at the topography of the previous macular
hole position (arrowhead) due to probable window defects related to
RPE atrophic changes
Figure 5
Intraoperative view of chronic macular hole submitted to ILM
peeling guided by brilliant blue 0.5mg/ml of brilliant blue staining
– OphthblueTM (Ophthalmos, Brazil); A – Initial step of
ILM peeling grasped by intraocula forceps;B – Intermediate phase of
maculorrhexis showing the blue ILM in contrast to the subjacent
unstained retina C – Final aspect of ILM peeling. Note the presence
of the white triamcinolone acetonide (into the macular hole)
previously used for posterior hyaloid detachment; D – Fluid-air
exchange. Note the air bubble inferiorly
Figure 6
Intraoperative view of macular hole surgery submitted to ILM
peeling guided by brilliant blue 0.5% staining –
OphthblueTM (Ophthalmos, Brazil) using the different
light sources: A – Vitreous base removal after phacoemulsification,
IOL implantation and posterior hyaloid detachment. The periphery of
the retina is observed by the surgeon’s indentation of the sclera
using the xenon light source – Photon II (Synergetics, USA) in a
4th sclerotomy; B – A more advanced stage of vitreous
base removal. The high definition of the image allows visualization
of possible retinal tears; C – The ILM peeling guided by brilliant
blue staining and the use of ambar filter from the Stellaris PCTM
light source (Bausch & Lomb, USA); note the easy observation of
ILM around the macular hole; D – Fluid air exchange using the ambar
filter from the Stellaris PCTM light source (Bausch &
Lomb, USA). No dispersion of light is observed due to the light
pipe
Figure 7
Summary of the ILM peeling techniques during the
chromovitrectomy: A - ILM peeling guided by ICG staining 0.5mg/ mL
in macular hole. A fast surgical procedure is advised and the light
pipe must be held far from the macula to mimize the possibility of
toxic effects; B - ILM peeling guided by brilliant blue 0.5mg/mL in
macular hole surgery; C - Brilliant blue 0.5mg/mL injection using
the soft tip during the infusion off. Care to avoid intense flush of
the dye is necessary; ILM peeling guided by the double staining
technique after ERM removal. Staining was performed by 0.2mL of
triamcinolone acetonide 40mg/mL along with 0.2mL of 0.5mg/mL of
brilliant blue
Figure 3
Peeling is facilitated because ICG produce an ILM stiffness and a
very good contrast to the retina
Figure 4
RPE changes after ILM peeling in macular hole surgery guided by
5mg/mL of indocyanine green; A - Fundus photography showing that
macular hole is sealed. However, pigmentary changes are observed
(arrow) and abnormal clinical aspect the previous macular hole
(arrowhead); B - Early phase of fluorescein angiogram showing
hypofluorescent image inferior to the previous macular hole (arrow)
and hyperfluorescent image at the topography of the previous macular
hole position (arrowhead) due to probable window defects related to
RPE atrophic changes
Figure 5
Intraoperative view of chronic macular hole submitted to ILM
peeling guided by brilliant blue 0.5mg/ml of brilliant blue staining
– OphthblueTM (Ophthalmos, Brazil); A – Initial step of
ILM peeling grasped by intraocula forceps;B – Intermediate phase of
maculorrhexis showing the blue ILM in contrast to the subjacent
unstained retina C – Final aspect of ILM peeling. Note the presence
of the white triamcinolone acetonide (into the macular hole)
previously used for posterior hyaloid detachment; D – Fluid-air
exchange. Note the air bubble inferiorly
Figure 6
Intraoperative view of macular hole surgery submitted to ILM
peeling guided by brilliant blue 0.5% staining –
OphthblueTM (Ophthalmos, Brazil) using the different
light sources: A – Vitreous base removal after phacoemulsification,
IOL implantation and posterior hyaloid detachment. The periphery of
the retina is observed by the surgeon’s indentation of the sclera
using the xenon light source – Photon II (Synergetics, USA) in a
4th sclerotomy; B – A more advanced stage of vitreous
base removal. The high definition of the image allows visualization
of possible retinal tears; C – The ILM peeling guided by brilliant
blue staining and the use of ambar filter from the Stellaris PCTM
light source (Bausch & Lomb, USA); note the easy observation of
ILM around the macular hole; D – Fluid air exchange using the ambar
filter from the Stellaris PCTM light source (Bausch &
Lomb, USA). No dispersion of light is observed due to the light
pipe
Figure 7
Summary of the ILM peeling techniques during the
chromovitrectomy: A - ILM peeling guided by ICG staining 0.5mg/ mL
in macular hole. A fast surgical procedure is advised and the light
pipe must be held far from the macula to mimize the possibility of
toxic effects; B - ILM peeling guided by brilliant blue 0.5mg/mL in
macular hole surgery; C - Brilliant blue 0.5mg/mL injection using
the soft tip during the infusion off. Care to avoid intense flush of
the dye is necessary; ILM peeling guided by the double staining
technique after ERM removal. Staining was performed by 0.2mL of
triamcinolone acetonide 40mg/mL along with 0.2mL of 0.5mg/mL of
brilliant blue
Figure 8
A combination of 0.3mL of TB 1.5mL/mL and 0.1mL f glucose 5% solution
injected in a fluid-filled technique; this dye solution is denser than
water that might avoid contact at the posterior capsule of the lens and
is helpful to maintain selective staining of posterior pole
Figure 9
Summary of the ERM peeling techniques during the chromovitrectomy: A
– ERM peeling using no dyes; B – ERM peeling using 0.2mL of
triancinolone ecetonide (TA) 40mg/mL; C – ERM peeling using trypan blue
(TB) 1.5mg/mL; D – ERM peeling using TA and TB, by the double-staining
technique. Staining was performed with 0.2mL of TA 40mg/ml and 0.2mL of
TB 1.5mg/m
Figure 10
Intraoperative view of chronic macular hole and ERM. After
ERM peeling, the ILM is stained for facilitate the peeling
procedure: A - Epiretinal peeling using intraocular forceps.
Note that triamcinolone previously used for posterior hyaloid
detachment is observed into the macular hole; B – Intravitreal
injection of brilliant blue (BB) 0.5mg/mL; C- ILM –peeling
guided by BB staining; DFluid air exchange following by laser at
the iatrogenic tear
Figure 11
Triancinolone acetonide - guided posterior hyaloid dissection; note
that TA crystals deposits to the acellular vitreous gel, providing a
clear visualization of the posterior vitreous cortex
Figure 12
Lutein 0.3% and BB 0.025% deposit onto the posterior pole during
vitrectomy for ERM: A – Intraoperative view of the injection. The higher
density of the dye allows gentle deposition onto the posterior pole without
the need for pressurized injection; B – Widespread staining of the posterior
pole obtained by deposition of the solution
Figure 13
Dye deposition at the posterior hyaloid and vitreous base in an eye with
a macular hole: A – The posterior hyaloid is detached and identified by
deposition of the lutein crystals; B –The late stage of removal of the
vitreous base aided by the golden crystals
Figure 14
Dye deposition at the ILM in an eye with a macular hole; A – An
intraoperative image shows the initial removal of the ILM stained blue by
BB; B – The intermediate phase of ILM peeling shows the tip of the forceps
grasping the blue-stained ILM
Figure 15
ILM peeling guided by the combination dye in an eye with PDR and macular
edema; A – An intraoperative image shows the initial ILM peeling in a
patient with PDR and DME; the initial traction can be seen at the ILM, which
is stained blue; the underlying retina is not stained blue. The hard
exudates under the macular edema have a yellowish appearance; B – The
intermediate stage of en bloc ILM removal; the yellowish-orange region in
the foveal region characterizes the retinal edema and adjacent macular
cysts; C – The late stage of ILM removal; the fovea is swollen; D – The
final stage of ILM peeling
Figure 16
Intraoperative findings during ILM peeling in cadaveric eyes guided by
staining with anthocianins from açai fruit (Euterpe
Oleracea): A – Initial surgical procedure; B – Progression of
ILM peeling procedure; C – ILM peeling is completed for 360 degrees; D – ILM
removed completely from cadaveric eye
Thumbnail
Thumbnail
Thumbnail
Thumbnail
Thumbnail
Thumbnail
Thumbnail
Thumbnail
Thumbnail
Thumbnail
Thumbnail
Thumbnail
Thumbnail
Thumbnail
Thumbnail
Thumbnail
