Efficacy of 0.15% trypan blue for staining and removal of the internal limiting membrane, epiretinal membranes, and the posterior hyaloid during pars plana vitrectomy.
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Basement Membrane↗
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Epiretinal membranes.
Epiretinal membranes are a common finding in older patients but are rare in young patients. Although they may be associated with other ocular conditions, most epiretinal membranes occur in the absence of ocular pathology. Patient symptoms range from asymptomatic to complaints of severe vision loss and metamorphopsia. Epiretinal membranes are commonly classified according to their density and contractile characteristics. In this review, cellophane maculopathy refers to thin, glistening membrane, surface wrinkling maculopathy is characterized by fine, superficial retinal folds and macular pucker is associated with a dense, grayish-white membrane causing a characteristic pattern of severe retinal distortion. With sufficient visual disturbance, epiretinal membranes may be treated by pars plana posterior vitrectomy and epiretinal membrane peeling.
Diagnosis, Differential↗
[Idiopathic and secondary epiretinal membranes. 1: The epiretinal membranes. 2: Surgery of epiretinal membranes].
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Humans↗
Macular epiretinal membranes.
Epiretinal membranes (ERM) are a common finding in older patients. Although they may be associated with numerous clinical conditions, most epiretinal membranes occur in the absence of ocular pathology. Patients symptoms range from asymptotic to complaints of severe vision loss and metamorphopsia. Epiretinal membranes are commonly classified according to their density, to the severity of retinal distortion and to associated biomicroscopic changes. Pars plana vitrectomy has been found to be effective in removing ERM from the macula, improving the visual acuity and decreasing metamorphopsia. Both idiopathic and secondary ERMs do well after surgery, although secondary ERMs showed a greater amount of improvement than idiopathic ones. Complications are frequent including accelerated postoperative nuclear sclerosis, retinal breaks and RD, macular edema, RPE and, occasionally, macular hole and hypotony. However only RD involving the macula have a worsening prognosis on final outcome.
Epiretinal Membrane↗
Proliferative activity and immunohistochemical cell differentiation in human epiretinal membranes.
Epiretinal membranes are a complex tissue mainly formed by the proliferation of retinal pigment epithelial cells, macrophages, glial cells, and fibroblasts. The proliferative contribution of these cells in regard of the formation of an epiretinal membrane is not yet clear. We determined the cellular proliferative activity by the use of the monoclonal antibody Ki-67 in 46 epiretinal membranes of proliferative vitreoretinopathy (PVR), PVR recurrences after intraocular silicone oil tamponade, proliferative diabetic retinopathy, and macular pucker. The proliferative activity of each membrane was indicated by the proliferative index (PI), which is the ratio of the actively proliferating Ki-67-positive cells and the total cell number in a cross-section of the membrane. The PI of each membrane was combined with the expression pattern of cell type associated antigens like cytokeratin for epithelial-like cells, KiM7 for macrophages, and glial fibrillary acidic protein for glial cells. Such a membrane typing revealed distinct interindividual differences, but no strict correlation with the underlying disease process. Our findings support the idea of an individual "fingerprint-like" membrane typing at the time of surgery combining the information about the antigen expression pattern of the participating cells and their functional proliferative state. Individual membrane typing for each patient might become clinically significant as soon as the dominating cells for tissue proliferation become key targets for specific pharmacological interventions.
Cell Differentiation↗
Effect of scleral buckling on vector forces caused by epiretinal membranes.
Epiretinal membranes exert a perpendicular force on the retina that is directed toward the center of the vitreous cavity and tends to elevate the retina from the retinal pigment epithelium. A scleral buckle changes the eye wall from concave to convex and reverses the direction of the vector force oriented perpendicular to the eye wall. Therefore, when a scleral buckle is used, the force from an epiretinal membrane pulls the retina toward the retinal pigment epithelium instead of causing retinal detachment.
Eye↗
Trypan blue staining of internal limiting membrane and epiretinal membrane during vitrectomy: visual results and histopathological findings.
AIMS: To report on the use of trypan blue (TB) 0.06% for staining the internal limiting membrane (ILM) and epiretinal membrane (ERM) during vitrectomy and report on their histology. METHOD: 14 consecutive patients with idiopathic macular hole or macular pucker (seven patients each) were prospectively recruited for ILM or ERM peel respectively. After pars plana vitrectomy and induction of posterior vitreous detachment, 0.5 ml TB 0.06% in phosphate buffered saline (VisonBlue) was injected over the posterior pole in an air filled eye and left for 2 minutes. The stained tissue was peeled with intraocular forceps. Specimens were evaluated using histochemical and immunohistochemical methods. RESULTS: The average follow up was 4.4 months. Internal limiting membranes and epiretinal membranes were stained satisfactorily in all cases and removed successfully. Eight patients (57%) had improvement of 2 or more Snellen lines. All seven macular holes closed. In the ERM cases, no residual membranes were observed clinically, at the latest follow up. No complications relating to the use of the dye were encountered intraoperatively or postoperatively. Of the 14 procedures, nine (four macular hole and five macular pucker) yielded sufficient tissue for histopathological evaluation. Histological and immunohistological assessment revealed that the morphology of these specimens was similar to that observed in macular hole ILM and macular pucker ERM removed without the aid of dye. CONCLUSION: TB staining facilitated the identification and delineation of ILM and ERM removal during the surgical management of macular holes and macular pucker. The visual outcome of this series and the specimens removed suggest they are no different from those without TB staining. Its use in posterior segment appears to be safe but further studies are required to investigate its long term safety.
Adult↗
Indocyanine green-assisted internal limiting membrane removal in epiretinal membrane surgery: a clinical and histologic study.
PURPOSE: To evaluate the clinical outcome and quantify histologically the amount of microscopic internal limiting membrane (ILM) and epiretinal membrane (ERM) present in ILM and ERM specimens obtained from ERM surgery. DESIGN: Interventional consecutive case series. METHODS: Patients scheduled for ERM surgery were recruited prospectively. Pars plana vitrectomy, removal of ERM, and ILM peeling with indocyanine green (ICG) staining were performed in all patients. Epiretinal membrane and ILM specimens were sent for histologic examination. The amount of ERM present in ILM specimens and the amount of ILM present in ERM specimens were quantified by manual counting. Outcome measures include change in best-corrected visual acuity (BCVA), proportion of cases with 2 or more lines of visual improvement, anatomic outcome, proportions of microscopic ERM within ILM, and microscopic ILM within ERM. RESULTS: Eighteen eyes in 18 patients were operated with a mean follow-up of 19.3 months. There were 13 primary ERMs and five secondary ERMs. The mean logMAR BCVA improved from 0.83 preoperatively to 0.49 postoperatively (P <.001). The mean lines of improvement in BCVA was 3.3 lines with 14 patients (77.8%) who had 2 or more lines of BCVA improvement. Histologic evaluation of the specimens showed no significant correlation with the final BCVA of 20/50 or better. Eleven (61.1%) of the ILM specimens showed various amount of microscopic ERM and 16 (88.9%) of the ERM specimens showed various amount of ILM fragments. The mean proportion of ERM within ILM specimens was 4.69% and that of ILM within ERM specimens was 51.5%. No significant recurrence of ERM was found. CONCLUSION: Recurrence of ERM may be minimized by removing residual microscopic ERM present on the ILM. Indocyanine green-assisted ILM peeling in ERM surgery appears to have favorable visual and anatomic outcomes.
Aged↗
[Long-term prognosis of internal limiting membrane peeling for idiopathic epiretinal membrane].
PURPOSE: To report the long-term prognosis of internal limiting membrane peeling for idiopathic epiretinal membrane. METHODS: Thirty-six patients eyes(37 eyes) who underwent internal limiting membrane peeling without indocyanine green staining to treat idiopathic epiretinal membranes between February 1998 and April 2000 were followed for at least 2 years postoperatively in the Ophthalmology Department of Osaka Rosai Hospital. We checked visual acuity (VA) preoperatively and at 1, 3, 6, 12, 18, and 24 months postoperatively and evaluated the progress of visual improvement. RESULTS: VA improved significantly during the first year postoperatively and stabilized thereafter. The percentages of eyes that showed a VA improvement of greater than 2 lines were 49, 57, 65%, and 73% at 3, 6, 12, and 24 months postoperatively, respectively. About 70% of the patients achieved VA exceeding 1.0 at 2 years postoperatively. Patients older than 70 years and those with a long duration of illness were slower to improve. Epiretinal membranes recurred in 3% of the patients. CONCLUSION: VA after internal limiting membrane peeling for idiopathic epiretinal membrane improved significantly during the first year postoperatively and the VA continued to improve thereafter. The recurrence rate was 3% internal limiting membrane peeling is the preferred treatment for idiopathic epiretinal membrane.
Age Factors↗
Clinicopathologic correlation of an eye after surgical removal of an epiretinal membrane.
An epiretinal membrane causing macular pucker was surgically removed from an eye that had previously undergone a scleral buckling procedure for retinal detachment. The eye was obtained postmortem and studies by light and electron microscopy disclosed a large area of retina that was void of internal limiting membrane (ILM). The presence of extremely thin ILM, and rare segments of basement membrane with an increased number of attachment plaques of Mueller cells near the margin of the area of ILM loss, suggested a limited capacity for regeneration of the ILM. Minor recurrence of fibrous astrocyte proliferation along the inner surface of the area devoid of ILM was observed. Recurrence of epiretinal membrane, without contraction changes, occurred at the margins of the area from which ILM had been removed.
Female↗
Localisation of vascular endothelial growth factor and its receptors to cells of vascular and avascular epiretinal membranes.
AIMS/BACKGROUND: Epiretinal membranes (ERMs) arise from a variety of causes or, in some cases, for unknown reasons. Once established, ERMs tend to progress, becoming more extensive and exerting increasing traction along the inner surface of the retina. One possible cause for their progression is the production of growth factors by cells within ERMs that may provide autocrine or paracrine stimulation. Platelet derived growth factor (PDGF) and its receptors have been localised to cells of ERMs and may play such a role. In this study, comparative data were sought for several other growth factors that have been implicated in ERM formation. METHODS: Immunohistochemical staining of ERMs was done for PDGF-A, PDGF-B, basic fibroblast growth factor (bFGF), three isoforms of transforming growth factor beta (TGF-beta), and vascular endothelial growth factor (VEGF) and its receptors, flt-1 and flk-1/KDR. Expression of flt-1 and flk-1/KDR was examined in cultured retinal pigmented epithelial (RPE) cells and retinal glia from postmortem eyes by immunohistochemistry and by reverse transcription coupled to polymerase chain reaction (RT-PCR). RESULTS: Staining was most intense and most frequently observed for VEGF and PDGF-A, both in vascular and avascular ERMs. The majority of cells stained for VEGF in nine of 11 (81.8%) diabetic ERMs and in 14 of 24 (58.3%) proliferative vitreoretinopathy ERMs. The receptors for VEGF, flt-1, and flk-1/KDR were also identified on cells in ERMs and on cultured RPE cells. By RT-PCR, mRNA for flt-1 was identified in RPE cells and retinal glia, and mRNA for flk-1/KDR was identified in RPE cells. CONCLUSIONS: These data show that VEGF and its receptors are localised to both vascular and avascular ERMs and suggest that VEGF, like PDGF-A, may be an autocrine and paracrine stimulator that may contribute to progression of vascular and avascular ERMs.
Endothelial Growth Factors↗
Indocyanine green-assisted internal limiting membrane removal in epiretinal membrane surgery.
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Basement Membrane↗
Plasminogen activation in epiretinal membranes.
BACKGROUND: Formation of epiretinal membranes occurs in proliferative vitreoretinopathy, macular pucker and after penetrating trauma. Epiretinal membrane formation includes cell migration and proliferation, extracellular matrix formation and tissue contraction. Generally in scar tissue formation, the production of new extracellular matrix occurs concomitantly with its proteolytic degradation, resulting in continuous tissue remodelling. The plasminogen activator-mediated proteolytic cascade is an important mechanism for pericellular degradation of the extracellular matrix. Therefore we wanted to study the presence of the plasminogen activator-mediated proteolytic cascade in epiretinal membranes. METHODS: Specimens of 18 epiretinal and 3 subretinal membranes were obtained during vitreous surgery for retinal detachment with proliferative vitreoretinopathy or macular pucker. Plasminogen activators and plasmin were characterized in frozen sections of epiretinal membranes by in situ zymography and in membrane lysates by zymography. Indirect immunofluorescence staining was performed to localize urokinase in epiretinal membranes. RESULTS: Urokinase was present in 17/21 and tissue-type plasminogen activator in 12/21 of the membranes studied. Active plasmin was not detected in the frozen sections of epiretinal membranes. Immunofluorescence staining localized urokinase predominantly in the areas invaded by macrophages and cells of retinal pigment epithelial origin. CONCLUSION: Our results demonstrate the presence of proteolytic activity in periretinal scar tissue. Urokinase was more consistently present, but smaller amounts of tissue-type plasminogen activator were also found in the specimens. These results indicate that continuous tissue remodelling with simultaneous extracellular matrix production and breakdown regulates the growth of epiretinal membranes.
Adult↗
Perifoveal microcirculation in eyes with epiretinal membranes.
BACKGROUND/AIMS: Eyes with epiretinal membranes (ERMs) often have alterations of retinal vessels. The authors studied perifoveal microcirculation in eyes with epiretinal membranes (ERMs) using scanning laser ophthalmoscope (SLO) fluorescein angiography. METHODS: Mean capillary blood flow velocity (CFV) was measured as an index of perifoveal microcirculation by SLO fluorescein angiography in 26 eyes with ERMs (19 eyes with idiopathic epiretinal membranes, seven eyes with epiretinal membranes after retinal detachment surgery) before and 6 months after vitreous surgery, and in 23 healthy control subjects. RESULTS: The mean CFV was significantly reduced in eyes with ERMs compared with healthy controls (p=0.012), and the postoperative mean CFV was significantly increased compared with the preoperative mean CFV (p=0.041). CONCLUSION: Significant changes of capillary blood flow velocity in the perifoveal areas were observed between normal subjects and eyes with epiretinal membranes. This indicates that eyes with ERMs show abnormal haemodynamics in the perifoveal capillaries.
Adult↗
[Role of trypan blue in epiretinal membrane surgery].
INTRODUCTION: Idiopathic epiretinal membrane (ERM) results from detachment of the posterior hyaloid. Vitrectomy and peeling are the treatment of choice. Trypan blue 0.15% (TB) stains the epiretinal membrane and the internal limiting membrane (ILM), facilitating surgery and thus allowing selective and complete removal with less retinal damage. We conducted a study evaluating the advantages of selective staining associated with surgery, the incidence of postoperative damage, and the influence on final visual acuity. MATERIAL AND METHODS: Fourteen patients were operated on by the same surgeon, who carried out a complete vitrectomy, then fluid-air exchange for dye injection of undiluted 0.2 ml of Trypan blue 0.15% in front of the membrane, which was then easily distinguished from the area under the retina. Preoperative visual acuity, postoperative damage, as well as eye status at the end of follow-up are discussed. Transmission electron microscopy was used to determine if epiretinal membrane removal was complete and selective. Angiography was systematically used to study the state of retina before and after surgery. RESULTS: Preliminary results show that trypan blue is useful and facilitates complete removal of ERM and ILM. It may reduce long-term complications and recurrent membrane formation. Trypan blue is a staining agent that is quick and easy to use. It presents no short-term toxic effects. Functional results in 6 months show improvement of visual acuity and disappearance of metamorphopsia. CONCLUSION: Idiopathic epiretinal membrane surgery with tryptan blue staining is a better alternative than indocyanine green staining.
Aged↗
[Immunohistochemical study of retinal Müller cell response in experimental epiretinal membrane formation].
Experimental epiretinal membranes (ERM) composed of Müller cells were formed by injecting autologous whole blood into the vitreous cavity of rabbits. Müller cell responses at the early stages of epiretinal membrane formation were studied using immunostaining of proliferative cell nuclear antigen (PCNA) (for identification of the proliferating cells) and glial fibrillary acidic protein (GFAP) (as an appropriate marker for glial cell response), and the electron microscope in the experimental rabbit model. Three days after the injection, nuclei of Müller cells were found in the inner part of the retina and were PCNA positive. PCNA positive staining was seen from day 3 to day 7. No PCNA-positive nuclei were seen at day 14 in the retina or ERM. A GFAP-positive reaction was first seen in the inner retina at day 3. Afterwards, the retina and the ERM were GFAP-positive in the experimental period. We concluded that activation and proliferation of Müller cells began at an early stage after the blood injection. Müller cells remained active and expanded onto the retinal surface.
Animals↗
[Prognostic factors in surgical treatment of epiretinal membranes].
BACKGROUND: Macular epiretinal membranes, whether idiopathic or secondary to vitreo-retinal pathology may result in a lowering of central vision and/or metamorphopsia following a distortion of retinal tissue. Although an adequate surgical peeling procedure is known to result in a functional improvement, the criteria for patient selection for such intervention are, as yet not clearly established. METHODS AND RESULTS: In order to establish prognostic indicators of a good visual recovery, we studied 25 cases of epiretinal membrane. Our results showed an improvement in visual acuity of 2 or more Snellen lines among 34% of our patients, regardless of their initial visual acuity. The duration of symptoms prior to intervention was found to be a prognostic factor whereas the presence of macular edema detected preoperatively on fluorescein angiography had no effect on the final visual outcome. CONCLUSION: A common post-operative complication came to our attention: secondary opacification of the crystalline lens.
Cataract↗
Natural history of fibrocellular epiretinal membranes: a quantitative, autoradiographic, and immunohistochemical study.
Quantitative, autoradiographic, or immunohistochemical light microscopy was conducted on 85 surgically excised epiretinal membranes to investigate the activities of component cells and the natural history of the extraretinal scars. Membranes of less than four months' clinical duration ('early' membranes) contained significantly more cells than 'late' membranes, while collagen was more abundant in the older specimens. No correlation was established between membrane opacification and either the cellularity or the collagen content of the membranes. Epiretinal membranes had some features in common with healing skin wounds, but the activities of cells in the epiretinal membranes were relatively protracted and disordered. Fibronectin was found to be a significant component of epiretinal membranes and therefore represents a target at which pharmacological intervention could be aimed.
Actins↗