-
- The Editor:
Dr. Paul Finger - The Editor:
|
Patient Information:
Contacts: |
|
Traction Maculopathy Macular Hole Cellophane Maculopathy Macular Pucker On Removing Traction From the Macula By
Robert Morris, MD and C. Douglas Witherspoon, MD
The
Problem:
Several forces can pull on the macula, wrinkle or displace the
retina, and cause distortion of vision. There are several causes
of macular traction. Causes of Traction Maculopathy: 1. The normal eye is filled with a gel called vitreous. When the vitreous gel liquefies with age, it often detaches (falls off) the back of the eye (macula). This process called "vitreous detachment" typically causes either no symptoms, flashes of light, floaters, or retinal detachment (rarely). Sometimes, the detaching vitreous can stick to the macula, pull on the macular retina, and cause a macular hole. This is called vitreomacular traction syndrome. 2. There is a second (more common) way the macula can be pulled or wrinkled. Cellophane maculopathy, macular pucker, and macular hole can also be caused by a gradual process of scarring of the inner surface (lining) of the retina. This scarring forms was is termed an "epiretinal membrane." Traction and scarring of the macular retina at first produces distortion and eventual loss of vision. Fluorescein angiogram can show leaking of affected blood vessels which can be reversed by surgery. This is important because leaking blood vessels can cause macular edema (swelling) particularly in diabetic eyes. This is also important because chronic edema can result in irreversible cystic retinal changes, foveal cysts and macular holes. Unlike the typical "wet" and "dry" ARMD where the problem occurs beneath the retina, in Traction Maculopathy (ARMD) the retinal surface is affected first. Also unlike typical ARMD, Traction Maculopathy due to epiretinal membrane formation is largely reversible (if treated early). It is important to note that while traction maculopathy may present as slightly distorted vision, it can gradually progress to reduce best corrected visual acuity to 20/200 (0.1, legal blindness). Lastly, Traction maculopathy affects both eyes in 10 to 30% of cases. Treatment: Epiretinal Membrane Surgery: In 1976, Machemer first removed epiretinal membranes during vitrectomy. Throughout the 1980's, removal of epiretinal membranes became more common, and macular surgery began to constitute an ever larger percentage of vitrectomies performed. The daunting challenge of restoring foveal function by traction release became a necessary part of each vitreoretinal surgeon's repertoire. In fact, it requires the most delicate hand movements of any surgery on the human body. Macular Hole Surgery: In 1991, Kelly and Wendel first reported successful closure of macular holes with substantial return of visual acuity. The pace of progress in our understanding of both the vitreoretinal interface and of traction maculopathy and its treatment quickened significantly, as innovative surgeons endeavored to improve upon the author's reported 50% anatomical hole closure rate. The Internal Limiting Membrane (ILM): Morris, Kuhn, and Witherspoon have suggested that removal of the entire macular ILM could be followed by long term, stable and excellent visual acuity. By 1993, They began using a procedure we called "ILM Maculorhexis" in the treatment of macular hole and epimacular proliferation. In 1994, we further predicted that removal of the internal limiting membrane might become an important part of surgery for all forms of traction maculopathy. Subsequent advocates of ILM removal such as Drs. Logan Brooks, Tom Rice, Tony Capone, Robert Wendel, and Claus Eckhardt, reported higher rates of macular hole closure with good visual results. Because the removal of ILM was technically difficult and prolonged macular surgery, and because of the possibility that it might affect the underlying neurosensory retina, ILM removal remained controversial. We believe that the experienced surgeon can successfully identify and remove the ILM. Intraoperative identification of the ILM has improved with the use of indocyanine green (ICG) ILM staining technique as described by Kim and Clark in 1999. The ILM direct-view forceps (Grieshaber), combined with ICG staining, now make ILM removal much more predictable. In an effort to make ILM removal easier, Morris and Witherspoon have developed the FILMS procedure. A FILMS cannulaŞ is inserted under the ILM in the peripheral macula. Using foot pedal control of a viscous fluid injector, viscoelastic fluid is slowly injected, establishing a cleavage plane (bubble or cyst) between the ILM and the remaining neurosensory retina. A FILMS cyst develops at a rate controlled by the surgeon. No hemorrhages were seen, probably reflecting the fact that there is no mechanical pulling on the retina, but rather gentle tamponade of the retina, as the ILM/EMP complex is elevated. The separated tissue was then easily removed with forceps. FILMS was the first surgery performed within the retina, separating the neurosensory layers from all overlying pathologic tissue. After clinical trials of the FILMS cannulaŞ and method, the device is expected to be available for patient care. Conclusion: There are several forces can pull on the macula, wrinkle or displace the retina, causing distortion of vision. An experienced retinal specialist can determine why there is retinal traction, when to consider surgery, and what method to employ. Clearly, great progress has been made over the last 20 years such that if caught early, most patients can be treated for Traction Maculopathy (macular hole, macular pucker, cellophane maculopathy). The
FILMS microcannulaŞ is patented: US patent #6210357. References 1.
Gass JD: Idiopathic Senile Macular Hole - It's Early Stages
and Pathogenesis. Arch Ophthalmol 1988; 106: 629-39. Support The EyeCare Foundation Please
report any problems to:webmaster@macular-degeneration.org
While this WWW site is intended to provide general information
as a public service, the content is not intended to represent
official policies and practices of the institution or to substitute
for health care provided by a clinician. Content and design
copyright © Paul
T. Finger,MD, FACS
|