A novel surgical technique of internal limiting membrane peeling for high myopic foveoschisis: a wide range of whole piece consecutive peeling without preservation of epi-fovea

Abstract

Aim: To demonstrate an improved surgical technique of whole piece consecutive internal limiting membrane (ILM) peeling without preservation of the epi-fovea to treat high myopic foveoschisis (MF).

Methods: A 23-gauge 3-port pars plana vitrectomy was performed on 16 patients with high MF. A parallel arc line along the vascular arcades was scraped out with a curved membrane scraper DSP. Next, an ILM forceps was used to catch hold of the incisal edge of the ILM flap, and the action of releasing and separating was subsequently taken toward the direction of the macular fovea. Next, the ILM forceps was used to grasp the released area, and the whole area coherent ILM peeling covering the macular fovea was implemented thereafter. Finally, the ILM was folded backwards and peeled off in the arc direction.

Results: At the final visit, the average central macular thickness decreased remarkably from 423.76±177.67 to 178.24±66.21 µm. The mean logarithm of the minimum angle of resolution best-corrected visual acuity of 1.37±0.59 was significantly alleviated to 0.74±0.59.

Conclusion: The wide range of whole piece consecutive ILM peeling without preservation of the epi-fovea is proven to be effective and significantly reduced the occurrence of retinal tear and macular hole.

Keywords: high myopic foveoschisis; internal limiting membrane peeling; macular hole; surgical technique.

Figure 1. The surgical procedure of the whole piece of consecutive ILM peeling covering the macular fovea

A: A parallel arc line along the inner side of the vascular arcades was scraped out with a curved membrane scraper DSP from the nasal side to the temporal side; B: An ILM forceps was used to catch hold of the incisal edge of the ILM flap on the nasal side and then the action of releasing and separating without stripping was taken toward the direction of macular fovea, which was repeated from the nasal side toward the temporal side coherently; C: The ILM forceps was used to grasp the release area near the middle and then a wide range of the whole area coherent ILM peeling covering the macular fovea was implemented; D: The ILM was folded backwards and peeled off in the arc direction and the whole piece of ILM was stripped off in a similar oval shape without the preservation of the macular fovea.

Figure 2. The schematic diagram of the whole piece of consecutive ILM peeling covering the macular fovea

A: A parallel arc line along the inner side of the vascular arcades was scraped out with an curved membrane scraper DSP from the nasal side to the temporal side; B: An ILM forceps was used to catch hold of the incisal edge of the ILM flap on the nasal side and then the action of releasing and separating without stripping was taken toward the direction of macular fovea, which was repeated from the nasal side toward the temporal side coherently; C: The ILM forceps was used to grasp the release area near the middle and then a wide range of the whole area coherent ILM peeling covering the macular fovea was implemented; D: The ILM was folded backwards and peeled off in the arc direction and the whole piece of ILM was stripped off in a similar oval shape without the preservation of the macular fovea.

Figure 3. The comparison of macular fovea images on OCT (5 cases) preoperatively and postoperatively

A1: Severe high MF both in the inner layer and outer layer of Case 3 preoperation; A2: The foveoschisis was alleviated and the macular fovea restored adhesion of Case 3 postoperation; B1: High MF in the outer layer and retinal detachment of Case 5 preoperation; B2: The foveoschisis improved greatly and the macular fovea restored adhesion of Case 5 postoperation; C1: High MF in the outer layer of Case 14 preoperation; C2: The foveoschisis disappeared gradually and the macular fovea restored local adhesion of Case 14 postoperation; D1: Severe high MF both in the inner layer and outer layer of Case 15 preoperation; D2: The foveoschisis disappeared significantly and the macular fovea restored obvious adhesion of Case 15 postoperation; E1: High MF in the outer layer and foveal detachment of Case 16 preoperation; E2: The foveoschisis disappeared fully and the macular fovea restored remarkable adhesion of Case 16 postoperation.

Figure 4. The schematic diagram of ILM peeling progress

A: The shape and location of the crack; B: The area A of the ILM before peeling and the equivalent crack length a_eff; C: The effective zone on the remaining structure of the retina and its length l and width t; D: A schematic diagram after peeling the ILM through the method of large piece consecutive peeling without preservation of epi-fovea. The green portion stands for ILM, and the orange portion represents retina.