Indocyanine green staining and removal of internal limiting membrane in macular hole surgery: histology and outcome

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Abstract

PURPOSE: To report the surgical technique, outcome, and histologic findings involving indocyanine green staining and removal of internal limiting membrane in primary macular hole surgery.

METHODS: Prospectively, consecutive patients with idiopathic macular hole or myopic macular hole with retinal detachment were recruited. After pars plana vitrectomy and epiretinal membrane removal, the internal limiting membrane was stained and removed. The specimens were stained using hematoxylin and eosin and periodic acid-Schiff. Immunohistochemical staining was also performed for glial fibrillary acidic protein, vimentin, type I and type IV collagen, and actin.

RESULTS: Among 10 patients (10 eyes) in the study, nine eyes had stage 3 or 4 macular hole. Four of them had chronic macular hole. The tenth patient had retinal detachment resulting from a myopic macular hole. Postoperatively, all cases had closure of macular hole without an elevated edge and the retina was attached. Seven patients had improvement of 2 or more Snellen lines, whereas visual acuity remained the same for the other three patients. In six eyes in which complete histologic examinations were feasible, internal limiting membrane was confirmed and two eyes also had a small amount of epiretinal membrane. Myofibrocytes in internal limiting membrane, either scattered or as a single layer, were found in three cases.

CONCLUSIONS: Removal of indocyanine green-stained internal limiting membrane around idiopathic macular hole or myopic macular hole with retinal detachment is confirmed with histology and may contribute to macular hole closure and retinal reattachment.

Section snippets

Methods

Commercially available indocyanine green preparation for fundus angiography was used (DiagnogreenInjection; Daiichi Pharmaceutical, Tokyo, Japan). Twenty-five milligrams of indocyanine green in the vial were reconstituted with the 10-ml solution provided; 0.5 ml of this solution was further diluted with 4.5 ml of balanced salt solution (Alcon, Fort Worth, Texas) to make up to 5 ml. The final concentration was 0.25 mg/ml. The osmolarity of this preparation was 293 mOsm, as compared with 291 mOsm

Results

Ten consecutive patients (10 eyes) were prospectively recruited. Patient demographics, diagnosis, and outcomes were tabulated in Table 1. The mean follow-up period was 3.6 months (range, 3 to 5 months). Nine eyes were stage 3 or stage 4 macular hole cases; four of them were chronic with more than 1-year duration. The tenth eye had a staphylomatous macular detachment secondary to a myopic macular hole. Intraoperatively, visible epiretinal membrane was only observed and removed in this eye. In

Discussion

In the present study, we have shown that indocyanine green staining followed by removal of internal limiting membrane was feasible in patients with macular hole with a favorable anatomical outcome. Similarly, Kadonosono and associates16 has recently reported an indocyanine green staining technique using a specially designed cannula with viscomaterial as a carrying medium. In their series of 13 patients with stage 3 or stage 4 macular holes, 92% attained anatomical closure. This is comparable to

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    This work was supported in part by the Mr. YT Cheng Eye Foundation, Hong Kong.

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