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      Effect of Iatrogenic Traction during Macular Peeling Surgery on Postoperative Microperimetry


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          Introduction: Vitrectomy with peeling of epiretinal membrane (ERM) and internal limiting membrane offers the chance for improvement of metamorphopsia and visual acuity. Microscope integrated intraoperative optical coherence tomography (iOCT) enables real-time imaging of retinal alterations during peeling, such as intraoperative transient retinal thickening owing to tractional forces during peeling. The aim of our study was to measure the amounts of transient retinal thickening due to tractional forces during membrane peeling, as documented with iOCT, and to analyze possible effects on postoperative retinal function. Methods: This prospective, monocenter study included patients scheduled for pars plana vitrectomy with membrane peeling due to an idiopathic ERM. During peeling, an iOCT device (ReScan700, Carl Zeiss Meditec AG) with continuous OCT-assistance during the peeling procedure, and video documentation of the peeling procedure, was used for the assessment of intraoperative transient retinal thickening owing to tractional forces during peeling. Directly before and 3 months after surgery, macular-OCT scans and microperimetry were performed. Results: Twenty-five eyes of 25 patients were included in the study. Microperimetry could be performed in all patients, while iOCT documentation could be analyzed in 22 patients. Transient retinal thickening owing to tractional forces during peeling could be observed in 14 patients (64%), with a median thickening to 143% of the normal (preoperative) retinal thickness at that location (IQR 132–163). Six patients (24%) developed new deep microscotomata as seen in microperimetry 3 months after surgery, among them were 2 patients who also had transient retinal thickening during peeling. Conclusion: New deep microscotomata developed only in a minority of patients with transient retinal thickening owing to tractional forces during peeling.

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          Most cited references19

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          Epiretinal cell proliferation in macular pucker and vitreomacular traction syndrome: analysis of flat-mounted internal limiting membrane specimens.

          To describe new details of epiretinal cell proliferation in flat-mounted internal limiting membrane specimens. One hundred nineteen internal limiting membrane specimens were removed en bloc with epiretinal membranes from 79 eyes with macular pucker (MP) and 40 eyes with vitreomacular traction syndrome. Intraoperatively, posterior vitreous detachment was assessed as complete or incomplete. Whole specimens were flat-mounted on glass slides and processed for interference and phase-contrast microscopy, cell viability assay, and immunocytochemistry. Mean cell viability percentage was higher in MP than in vitreomacular traction syndrome. Two cell distribution patterns were found. Anti-CD163 labeling presented predominantly in MP with complete posterior vitreous detachment. CD45 expression was similar in all groups of diagnosis. Anti-glial fibrillary acidic protein (GFAP) labeling was found in MP irrespective of the extent of posterior vitreous detachment. Alpha-SMA (α-smooth muscle actin) labeling was mainly presented in MP with incomplete posterior vitreous detachment and in vitreomacular traction syndrome. Simultaneous antibody labeling included GFAP/CD45, GFAP/CD163, CD163/CD45, and CD163/α-SMA. Hyalocytes constitute a major cell type of epiretinal cell proliferation in eyes with MP and vitreomacular traction syndrome. Glial cells, notably retinal Muller cells, are involved as well. It appears that transdifferentiation of cells in vitreomacular traction might be more frequent than previously thought and that those cells possess a greater variability of immunocytochemical properties than expected.
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            Macular pucker: to peel or not to peel the internal limiting membrane? A microperimetric response.

            To compare functional and anatomical outcomes after idiopathic macular pucker removal between eyes that underwent internal limiting membrane (ILM) peeling and eyes that did not.
              • Record: found
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              • Article: not found

              Possible contribution of hyalocytes to idiopathic epiretinal membrane formation and its contraction.

              To address the cellular components and the contractile mechanisms of the idiopathic epiretinal membrane (ERM). Ten surgically removed ERMs were fixed in 4% paraformaldehyde and analysed by whole-mount immunohistochemistry with anti-glial fibrillar acidic protein (GFAP) and alpha smooth-muscle actin (alphaSMA) antibodies. Type I collagen gel contraction assay, an established wound-healing assay in vitro, was performed using cultured bovine hyalocytes or normal human astrocytes (NHA) to evaluate the contractile property of the cells in the presence of tissue growth factor (TGF)-beta2. The expression of alphaSMA was also analysed by western blot analysis to examine myofibroblastic transdifferentiation of the cells. Vitreous-induced collagen gel contraction was also evaluated. All membranes were composed of alphaSMA immunopositive cells in contracted foci and GFAP immunopositive cells in the periphery. No apparent double positive cells were observed in any membranes examined. Cultured hyalocytes showed overexpression of alphaSMA and hypercontraction of collagen gels in response to TGF-beta2, while glial cells showed marginal change. The vitreous from ERM patients also caused overexpression of alphaSMA and hypercontraction of the gels embedding hyalocytes, which were almost completely inhibited in the presence of anti-TGF-beta2 neutralising antibody. Hyalocytes might be one of the critical components of ERM mediating its contractile property through the effect of TGF-beta2 in the vitreous fluid.

                Author and article information

                Ophthalmic Res
                Ophthalmic Research
                S. Karger AG
                March 2021
                01 April 2020
                : 64
                : 2
                : 273-279
                VIROS – Vienna Institute for Research in Ocular Surgery, A Karl Landsteiner Institute, Hanusch Hospital, Vienna, Austria
                Author notes
                *Oliver Findl, Hanusch Hospital, Heinrich Collin Strasse 30, AT–1140 Vienna (Austria), oliver@findl.at
                Author information
                507633 Ophthalmic Res 2021;64:273–279
                © 2020 S. Karger AG, Basel

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                : 24 June 2019
                : 30 March 2020
                Page count
                Figures: 4, Pages: 7
                Research Article

                Vision sciences,Ophthalmology & Optometry,Pathology
                Membrane peeling,Intraoperative Optical Coherence Tomography,Epiretinal membranes,Microperimetry


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