•Trim the remaining vitreous as much as possible.

•Stain and peel the ILM up to the vascular arcades.

– The retina may be fragile, especially if the condition is long-standing.

•Consider prophylactic laser cerclage (see Sect. 30.3.3).

50.2.2 Cellophane Maculopathy

•Perform a minimal to subtotal PPV.

•Stain (this makes the microfolds much more visible; see Fig. 50.4) and remove the ILM in the macular area.

Q&A

Q Why are the ILM folds more visible after staining than before?

A The dye pools in the “valleys” of the wrinkled surface while the ridges show only minimal staining (see Sect. 34.3).

–The wrinkled ILM must never be grabbed with the forceps jaws being parallel to, only perpendicular with, the direction of the folds (see Sect. 34.3 and

Fig. 32.10b, c).

Fig. 50.4 Cellophane maculopathy, intraoperative view. The folds are more clearly visible after ILM staining; the remaining TA crystals are also helpful in showing the partial-thickness retinal folds

50.2.3 Macular Pucker

•Most of these eyes already have a PVD; still, make sure that a PVD has occurred.

•Perform a minimal to subtotal PPV.

•Remove the epimacular membrane (see Sect. 32.2 for details).

–If you want to see the true size of the membrane, switch the light pipe to the other hand; the light now arrives at a different angle and may give a better view of the membrane.12

•Stain and remove the ILM.

–While this is not an absolutely necessary step, it ensures that no proliferation is left on the surface13 and that no recurrence occurs.

Q&A

Q Should you leave gas after the EMP has been removed?

AIf the ILM has been peeled, gas “tamponade” and positioning are really not necessary. There is nothing wrong employing them, however – except if the membrane has caused a true retinal elevation in the center and stretched the retina. If gas is used, this may cause a retinal fold.

50.2.4 Macular Hole

•Start the vitrectomy in front of the posterior pole and create a small pocket just above the macula.

•Create a PVD.

•Perform a minimal to subtotal PPV.

•Stain and remove the ILM.

–The macula is usually healthy, making the ILM removal relatively easy.

–Still, the hole may be enlarged if traction is exerted on the edge; always peel in a centripetal, never in a centrifugal, direction (see Fig. 50.5).

–The ILM may be missing in a tiny circle around the hole.

–Extend the peeling area up to vascular arcades.14

–Some surgeons use a variation of this technique by peeling only on one side of the hole, turn upside-down the still-attached portion of the ILM, and cover the hole with it (“inverted flap”).

•Perform a F-A-X.

–I use a soft-tipped extrusion needle to drain all remaining subretinal fluid (“cuff”); this also prevents ICG from persisting subretinally (Sect. 34.3.3.). Such drainage should be done only if visualization is optimal, which requires adjusting the BIOM.15 The RPE must never be touched with the silicone tubing; hold the tip just above the hole, never inside it (see Fig. 50.6).

–Often the hole closes intraoperatively as a result of the aspiration.

12 A superior solution is to use the slit lamp for pucker removal (see Sect. 17.2).

13Remember, the EMP may be multilayered.

14Some surgeons peel a much smaller area. The fact that when the hole does not close after the first surgery and these very same surgeons peel in a larger area during reoperation suggests that the initial failure could have been avoided by a larger peel.

15Upward movement of the front lens (see Sect. 31.2).

Fig. 50.5 Peeling the ILM in an eye with a macular hole. (a) The initial step is the creation of a vertical strip toward the hole (centripetal direction). (b) As soon as the ILM separation, which is done very slowly when being close to the fovea, reaches the hole, the peeling stops. (c) The direction of the peeling, which was from 12 o’clock toward 6 o’clock before, changes to a sideway direction (from 9 o’clock toward 3 o’clock from the surgeon’s point of view). (d) Once the ILM has been separated at the inferior edge of the hole, the direction of the peeling is changed again, and the ILM is pulled toward 12 o’clock. With this motion, the ILM adjacent to the hole has been completely lifted; the peeling area can then be extended toward the vascular arcade (not shown here)

•Use gas for tamponade and repeat what you told the patient preoperatively about positioning.

Pearl

I ask them to be facedown for 1 week. It is possible that a shorter period also suffices, but I explain to my patients that this inconvenience is their contribution to the cure. They will not have to blame themselves postoperatively in case of a failure: “Maybe if I had indeed positioned longer….”

ST

Fig. 50.6 Draining the subretinal fluid through the macular hole. (a) On this schematic image a thin fluid film (FF) still covers the retinal surface (R) after F-A-X. There is also fluid inside the hole and underneath the retinal edge around the hole (“cuff”). (b) The soft-tipped cannula (ST) is dipped into the fluid meniscus above the hole. The capillary action of the flute needle results in instant drainage. The contour of the fluid film changes from a purely retina-parallel one into a concave contour around the silicone tube (arrows pointing to the “shoulders” of the uplifted fluid), showing the cohesive attraction between the tube and the fluid. (c) Intraoperative image showing how the surgeon recognizes whether the tip of the silicone cannula “touched water” or is still in air, as in this picture. (d) Once the soft tip of the flute needle reaches the fluid film and its contour changes, light is reflected back from the fluid shoulders, instantly informing the surgeon that he must not push the cannula any deeper. As long as this position is maintained, the fluid will drain. However, because fluid keeps on flowing toward the fovea from the entire retinal surface, the maneuver must be repeated several times