Support for internal limiting membrane peeling for full-thickness macular holes

By Lucy Piper, Senior medwireNews Reporter

Vitrectomy with peeling of the internal limiting membrane (ILM) of the retina improves the outcome of idiopathic full-thickness macular hole (FTMH) surgery compared with no peeling, study findings show.

“The rationale for ILM peeling is to relieve tractional forces occurring around the fovea and ensure that any epiretinal tissue that could cause foveal traction, including epiretinal membranes, is removed,” say researchers, led by Noemi Lois, from Queens University in Belfast, UK.

Their systematic review and meta-analysis of data from four randomised controlled trials involving 314 patients indicated that peeling in 162 patients improved best-corrected distance visual acuity at 3 months compared with no peeling in 152, with a mean difference of –0.09.

However, there was no difference in visual acuity at 6 months, note the researchers, who explain that by this time, most of the patients who did not initially receive peeling had undergone the procedure as part of further surgery for failed macular hole closure, in line with standard clinical practice.

Macular hole closure was significantly more likely to occur in patients in the peeling group, at an odds ratio of 9.27 for primary hole closure and 3.99 for final hole closure. And the patients’ likelihood of needing additional surgery was reduced by a significant 89% with ILM peeling.

These benefits occurred without an increase in intraoperative or postoperative complications, rates of which were lower with ILM peeling, albeit not significantly so, the researchers write in Ophthalmology.

Patient-reported outcomes at 6 months were similar between the two groups, based on data from one trial. This may, again, reflect the fact that most patients in the no-peel group had received ILM peeling by then and suggests “that it is the final result (improved vision and quality of life) rather than what happens on the way to achieving it (e.g., surgery, hospital visits) that seems to be influencing patients most”, say Lois and colleagues.

These findings, and evidence from one trial that ILM peeling is “highly likely” to be cost-effective compared with no peeling, lead the researchers to believe “that this therapeutic approach may be the most advisable for the treatment patients with idiopathic FTMH.”

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