Ultrastructure of the Internal Limiting Membrane Removed During Macular Hole and Diabetic Macular Edema Surgery

Gi Hong Koo; Ji Eun Lee; Hee Young Choi; Boo Sup Oum

doi:10.3341/jkos.2010.51.1.42

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Koo, Lee, Choi, and Oum: Ultrastructure of the Internal Limiting Membrane Removed During Macular Hole and Diabetic Macular Edema Surgery

Original Article

J Korean Ophthalmol Soc 2010;51(1):42-48.

Published online: 7 September 2010

DOI: https://doi.org/10.3341/jkos.2010.51.1.42

Ultrastructure of the Internal Limiting Membrane Removed During Macular Hole and Diabetic Macular Edema Surgery

Gi Hong Koo, MD¹, Ji Eun Lee, MD, PhD^1,², Hee Young Choi, MD, PhD^1,², Boo Sup Oum, MD, PhD^1,²

¹Department of Ophthalmology, School of Medicine, Pusan National University, Busan, Korea

²Medical Research Institute, Pusan National University, Busan, Korea

Address reprint requests to Boo Sup Oum, MD, PhD Department of Ophthalmology, Pusan National University Hospital #1-10 Ami-dong, Seo-gu, Busan 602-739, Korea Tel: 82-51-240-7321, Fax: 82-51-242-7341, E-mail: bsoum@pusan.ac.kr

Received 13 January 2009 Accepted 22 September 2009

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

To evaluate retinal damage following internal limiting membrane (ILM) peeling in macular hole and diabetic macular edema (DME) surgeries.

Methods

Forty-five eyes with macular holes and thirty-five eyes with DME underwent pars plana vitrectomy with ILM peeling. The structures of the ILM were investigated using transmission electron microscopy, and the grades of retinal tissue damage were analyzed. We additionally observed the clinicopathologic association of retinal damage with the development of retinal hemorrhage during ILM peeling and that seen with indocyanine green (ICG) staining.

Results

In all specimens, cellular fragments were observed on the retinal side of the ILM in both macular hole and DME patients. The thickness of the ILM in DME significantly increased (3.13±1.12 μ m compared with that in patients with macular holes (2.41±0.77 μ m, p=0.002). The frequency of minute retinal bleeding during ILM peeling was higher in macular hole patients (46.7%) than in those with diabetic macular edema (22.9%m p=0.028). Twenty-two eyes of 45 macular hole patients (48.9%) and 16 eyes of 35 DME patients (45.7%) had relative retinal damage. Overall, ILM performed in eyes which had minute bleeding during the peeling had more retinal damage (62.1%) than did those without hemorrhage (39.2%, p=0.049). ICG staining did not appear to influence retinal damage (p=0.81).

Conclusions

ILM peeling can cause minor, but demonstrable, damage of the adjacent retina.

Keywords: Internal limiting membrane, Müller cell

References

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Figure 1.

Transmission electron microscopic findings of the internal limiting membrane (ILM) removed during macular hole surgery. Only a few very tiny cellular fragments (arrow) are observed on the retinal side (R) of the ILM. The vitreous side (V) shows a very smooth surface. (×3,000)

Figure. 2.

Many cellular debris of Müller cells (arrow) are adherent to the retinal surface (R) of the internal limiting membrane (asterisk) in diabetic macular edema. A red blood cell is visible. (arrowhead). Collagen and cellular elements cover the vitreous side (V) of the internal limiting membrane (×3,000).

Figure 3.

Stretching forces split adjacent retinal structures (arrow) during the peeling of ILM in diabetic macular edema. The plasma membrane of Müller cells and other undetermined large cellular fragments (arrowhead) are adherent to the retinal surface of the ILM (×5,000).

Figure 4.

Partial tear of the internal limiting membrane (arrow) is seen in diabetic macular edema (×6,000).

Table 1.

Demographic data

Macular hole
Age (yrs)	63.3 (19∼85)
Sex (M/F)	14/31
Stage 2	8
Stage 3	13
Stage 4	24

Diabetic macular edema
Age (yrs)	61.5 (50∼75)
Sex (M/F)	19/16
DM Duration (yrs)	13.8 (±7.6)
Type 1/Type 2	0/35
NPDR/PDR	4/31

Table 2.

Mean ILM thickness, frequency of relative retinal damages and retinal hemorrhages in two groups

	Macular hole (n=45)	Diabetic macular edema (n=35)	p-value
ILM thickness (μm)	2.41±0.77	3.13±1.12	0.002^*
Retinal damage	22 (48.9)	16 (45.7)	0.78^†
Retinal hemorrhage	21 (46.7)	8 (22.9)	0.028^†

No. of eyes/Total numbers (%)

^* Independent-samples T test

^† Pearson chi-square test.

Table 3.

Association of retinal damage with development of retinal hemorrhage during ILM peeling

	Macular hole (n=45)		Diabetic macular edema (n=35)		Total (n=80)
	HM^* (+)	HM (−)	HM (+)	HM (−)	HM (+)	HM (−)
DMG^† (+)	12 (57.1)	10 (41.7)	6 (75.0)	10 (37.0)	18 (62.1)	20 (39.2)
DMG (−)	9 (42.9)	14 (58.3)	2 (25.0)	17 (63.0)	11 (37.9)	31 (60.8)
Total	21 (46.7)	24 (53.3)	8 (22.6)	24 (77.4)	29 (36.3)	51 (63.7)
p-value	0.30^‡		0.11^§		0.049^‡

^* HM=retinal hemorrhage

^† DMG=retinal damage

^‡ Pearson chi-square test

^§ Fisher's exact test.

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