Fig. 5.20 The same membrane is now removed completely with the Eckardt forceps

Pits & Pearls

PVD and hole closure: If you are unable to perform a safe ILM peeling in macular hole because of a bad view, etc., make sure that you induced a PVD and finish the case without ILM peeling. This achieves a hole closure in about 60–80% of cases. Multiple unsuccessful attempts to peel the ILM may cause more harm than be of benefit.

Peeling of epiretinal membrane

Try to mobilize the membrane with a membrane pic or scrape the membrane with the neurotomy knife (temporal, superior or inferior to the macula) until a small defect is created. Once an edge is mobilized, it can be grasped with Eckardt forceps (Fig. 5.19). Pull parallel to the retina until the complete membrane is removed (Fig. 5.20). If the membrane is strongly attached to the retina, do not insist – you might create a retinal defect. If the edges of the membrane tear off and you no longer recognize them, stain again instead and avoid poking around in the retina with the forceps.

You (as a beginner) should work very carefully within the papillomacular bundle. You might create irreversible visual field defects. Therefore, you should never start the ILM rhexis in the papillomacular bundle, but in an area with a good staining superior, inferior or temporal to the macula. Small retinal bleedings may occur during peeling. They will cause no harm and vanish within 1 month.

When the removal of the epiretinal membrane has succeeded change to the 120D lens and, with the help of scleral indentation, examine the retinal periphery for breaks.

Pits & Pearls

Membrane and dye: Staining the membrane repeatedly is recommended, as there are often several membranes present. The better the membrane is made visible, the easier it can be peeled.

Pits & Pearls No. 41

ILM peeling and dot haemorrhages: If you are unsure if you are peeling an ERM or an ILM, small dot haemorrhages only occur during ILM peeling and do not appear with ERM peeling.

Pits & Pearls No. 42

In cases of ERM, you can try a ‘two in one’ peeling of ERM and ILM by starting your peeling more peripheral than usual (for example, at the major vessel arcades). If you manage to grasp the ILM, continue your peeling towards the centre. The ERM should sit on top of the ILM, and both layers can be removed with one peeling.

6. Tamponade for macular hole

To carry out the gas tamponade, position the fluid tip above the optic disc, then switch to fluid–air exchange. The air streaming in has a different refractive index than water; therefore, the image becomes blurred but more wide-angled. You can focus the image by turning the focus wheel of the BIOM so that the front lens moves up. The image will come into focus again. Since a complete aspiration of BSS is not necessary, avoid an optic disc touch (optic neuropathy). Inject 20% SF6 into the vitreous cavity and decompress the eye by holding the fluid needle in a cannula. Open and close the side opening of the fluid needle with your index finger depending on the tension of the globe (Fig. 5.21). The intraocular pressure is checked with the index finger of the other hand.