International Ophthalmology

, Volume 34, Issue 2, pp 437–446 | Cite as

Early and late inner retinal changes after inner limiting membrane peeling

  • Francesco Pichi
  • Andrea Lembo
  • Mariachiara Morara
  • Chiara Veronese
  • Micol Alkabes
  • Paolo Nucci
  • Antonio P. Ciardella


Pars plana vitrectomy and inner limiting membrane (ILM) peeling are standard procedures for macular hole and epiretinal membrane surgery. However, ILM peeling is known to cause mechanical traumatic changes to the retinal nerve fiber layer. Recently there have been numerous reports of anatomical changes in the macula after ILM removal. A comprehensive review of the literature. The earliest change in the macula after ILM peeling is post-operative swelling of the arcuate retinal nerve fiber layer (SANFL), which disappears within the 3 month; the swelling is not detected on biomicroscopic fundus examination but appears as hypoautofluorescent arcuate striae in the macular region on infrared and autofluorescence imaging, with corresponding hyperreflectant swelling demonstrated on spectral-domain optical coherence tomography (OCT). SANFL is followed by dissociated optic nerve fiber layer defect, faintly visible on fundus examination and corresponding on OCT to “dimples” in the inner retinal layers. The en face tomographic aspect of this defect appears as concentric macular dark spots. Post-operative foveal displacement toward the optic disc might be responsible for the stretching and thinning of the retinal parenchyma in the temporal subfield and the thickening of the nasal macula. This shortening of the papillofoveal distance after surgery is probably secondary to axonal transport and contractility alterations in the nerve fiber layer, which might also account for apoptotic and atrophic degeneration of the peripapillary retinal nerve fiber layer. Ganglion cells do not seem to be affected by ILM peeling, even if the ganglion cell complex loses some volume because of trauma to the Müller cells contained in the ganglion cell layer. Despite its clear indication in macular hole and epiretinal membrane surgery, ILM peeling is a traumatic procedure that has acute effects on the underlying inner retinal layers. Further investigation of these subclinical changes may assist in aiding the development of minimally traumatic techniques for ILM removal.


ILM peeling SANFL DONFL Macular thinning 


  1. 1.
    Sebag J (1992) The vitreous. In: Hart WM (ed) Adler’s physiology of the eye, 9th edn. Mosby-Year Book, Baltimore, pp 268–347Google Scholar
  2. 2.
    Wollensak G, Spoerl E (2004) Biomechanical characteristics of retina. Retina 24:967–970PubMedCrossRefGoogle Scholar
  3. 3.
    Wollensak G, Spoerl E, Grosse G, Wirbelauer C (2006) Biomechanical significance of the human internal limiting lamina. Retina 26(8):965–968PubMedCrossRefGoogle Scholar
  4. 4.
    Ducournau D, Ducournau Y (2008) A closer look to the ILM. Retin Phys 5(Suppl. 6):4–15Google Scholar
  5. 5.
    Gass JDM (1988) Idiopathic senile macular hole. Its early stages and pathogenesis. Arch Ophthalmol 106:629–639PubMedCrossRefGoogle Scholar
  6. 6.
    Kelly NE, Wendel RT (1991) Vitreous surgery for idiopathic macular holes. Results of a pilot study. Arch Ophthalmol 109:654–659PubMedCrossRefGoogle Scholar
  7. 7.
    Schumann RG, Schaumberger MM, Rohleder M et al (2006) Ultrastructure of the vitreomacular interface in full-thickness idiopathic macular holes: a consecutive analysis of 100 cases. Am J Ophthalmol 141:1112–1119PubMedCrossRefGoogle Scholar
  8. 8.
    Wolf S, Schnurbusch U, Wiedemann P, Grosche J, Reichenbach A, Wolburg H (2004) Peeling of the basal membrane in the human retina: ultrastructural effects. Ophthalmology 111:238–243PubMedCrossRefGoogle Scholar
  9. 9.
    Haritoglou C, Gass C, Schaumberger M, Ehrt O, Gandorfer A, Kampik A (2001) Macular changes after peeling of the internal limiting membrane in macular hole surgery. Am J Ophthalmol 132:363–368PubMedCrossRefGoogle Scholar
  10. 10.
    Christensen UC, Kroyer K, Sander B et al (2009) Value of internal limiting membrane peeling in surgery idiopathic macular hole stage 2 and 3: a randomized clinical trial. Br J Ophthalmol 93:1005–1015PubMedCrossRefGoogle Scholar
  11. 11.
    Clark A, Balducci N, Pichi F, Veronese C, Morara M, Torrazza C, Ciardella AP (2012) Swelling of the arcuate nerve fiber layer after internal limiting membrane peeling. Retina 32(8):1608–1613PubMedCrossRefGoogle Scholar
  12. 12.
    Tadayoni R, Paques M, Massin P et al (2001) Dissociated optic nerve fiber layer appearance of the fundus after idiopathic epiretinal membrane removal. Ophthalmology 108:2279–2283PubMedCrossRefGoogle Scholar
  13. 13.
    Chihara E, Chihara K (1992) Apparent cleavage of the retinal nerve fiber layer in asymptomatic eyes with high myopia. Graefes Arch Clin Exp Ophthalmol 230:416–420PubMedCrossRefGoogle Scholar
  14. 14.
    Foos RY (1972) Vitreoretinal juncture; topographical variations. Invest Ophthalmol 11:801–808PubMedGoogle Scholar
  15. 15.
    Brazitikos PD, Katsimpris JM, Tsironi E, Androudi S (2010) Retinal nerve fiber layer thickness evaluation after trypan blue-assisted macular surgery. Retina 30:640–647PubMedCrossRefGoogle Scholar
  16. 16.
    Ito Y, Terasaki H, Takahashi A, Yamakoshi T, Kondo M, Nakamura M (2005) Dissociated optic nerve fiber layer after internal limiting membrane peeling for idiopathic macular holes. Ophthalmology 112:1415–1420PubMedCrossRefGoogle Scholar
  17. 17.
    Mitamura Y, Ohtsuka K (2005) Relationship of dissociated optic nerve fiber layer appearance to internal limiting membrane peeling. Ophthalmology 112:1766–1770PubMedCrossRefGoogle Scholar
  18. 18.
    Mitamura Y, Suzuki T, Kinoshita T et al (2004) Optical coherence tomographic findings of dissociated optic nerve fiber layer appearance. Am J Ophthalmol 137:1155–1156PubMedCrossRefGoogle Scholar
  19. 19.
    Alkabes M, Salinas C, Vitale L, Burès A, Nucci P, Mateo C (2011) En face optical coherence tomography of inner retinal defects after internal limiting membrane peeling for idiopathic macular hole. Invest Ophthalmol Vis Sci 52(11):8349–8355PubMedCrossRefGoogle Scholar
  20. 20.
    Spaide RF (2012) “Dissociated optic nerve fiber layer” appearance after internal limiting membrane removal is inner retinal dimpling. Retina 32(9):1719–1726PubMedCrossRefGoogle Scholar
  21. 21.
    Treumer F, Wacker N, Junge O, Hedderich J, Roider J, Hillenkamp J (2011) Foveal structure and thickness of retinal layers long-term after surgical peeling of idiopathic epiretinal membrane. Invest Ophthalmol Vis Sci 52:744–750PubMedCrossRefGoogle Scholar
  22. 22.
    Aso H, Iijima H, Imai M, Gotoh T (2009) Temporal changes in retinal thickness after removal of the epiretinal membrane. Acta Ophthalmol 87:419–423PubMedCrossRefGoogle Scholar
  23. 23.
    Yamashita T, Uemura A, Kita H, Sakamoto T (2006) Analysis of the retinal nerve fiber layer after indocyanine green-assisted vitrectomy for idiopathic macular hole. Ophthalmology 113:280–284PubMedCrossRefGoogle Scholar
  24. 24.
    Ejstrup R, la Cour M, Heegaard S, Kiilgaard JF (2012) Toxicity profiles of subretinal indocyanine green, brilliant blue G, and triamcinolone acetonide: a comparative study. Graefes Arch Clin Exp Ophthalmol 250(5):669–677PubMedCrossRefGoogle Scholar
  25. 25.
    Shukla D, Kalliath J, Neelakantan N, Naresh KB, Ramasamy K (2011) A comparison of brilliant blue G, trypan blue, and indocyanine green dyes to assist internal limiting membrane peeling during macular hole surgery. Retina 31:2021–2025PubMedCrossRefGoogle Scholar
  26. 26.
    Mitamura Y, Suzuki T, Kinoshita T, Miyano N, Tashimo A, Ohtsuka K (2004) Optical coherence tomographic findings of dissociated optic nerve fiber layer appearance. Am J Ophthalmol 137(6):1155–1156PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media Dordrecht 2013

Authors and Affiliations

  • Francesco Pichi
    • 1
  • Andrea Lembo
    • 1
  • Mariachiara Morara
    • 2
  • Chiara Veronese
    • 2
  • Micol Alkabes
    • 1
  • Paolo Nucci
    • 1
  • Antonio P. Ciardella
    • 2
  1. 1.San Giuseppe HospitalUniversity Eye ClinicMilanItaly
  2. 2.Ophthalmology UnitSant’Orsola-Malpighi HospitalBolognaItaly

Personalised recommendations