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    Paradigm shifting for ILM peeling, prone position after vitrectomy

    Take-home: Peeling of the internal limiting membrane has increasingly become a dogma of surgical retina, while maintenance of the face-down positioning may become anachronistic in many cases.  

    Reviewed by Gaetano R. Barile, MD

    Certain principles in ophthalmology are long established and adhered to by surgeons, in some cases for decades. But questions regarding two surgical practices–internal membrane peeling (ILM) during vitrectomy and maintaining the facedown position after vitrectomy with gas tamponade–are now being raised.

    The retina subspecialty has enjoyed significant advances resulting in improvements in anatomic and visual outcomes after vitrectomy. For example, instrumentation has improved dramatically because of engineering efforts.

    Especially in retinal diseases in which superior visualization is vital, wide-angle viewing has improved the surgeon’s vantage point and dyes facilitate ILM peeling. Surgical techniques, including the use of pharmacologic adjuvants, have advanced to treat diabetic retinopathy and proliferative vitreoretinopathy among other indications, according to Gaetano Barile, MD.

    The intraoperative goal in patients with vitreoretinal diseases is restoration of the retinal anatomy by removing traction from the vitreous and the retinal surface in retinal detachment, vitreomacular traction, macular holes and puckers, and retinal complications associated with longer axial lengths. In more complex cases, subretinal and intraretinal disease may need to be addressed, Dr. Barile explained.

    However, Dr. Barile, professor of ophthalmology, Hofstra Northwell School of Medicine, Manhattan Eye, Ear and Throat Hospital, New York, questioned if ILM peeling and maintenance of the facedown position after vitrectomy are necessary in order to restore the retinal anatomy.

    To peel or not to peel...?

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