19 Pakistan Journal of Ophthalmology, 2020, Vol. 36 (1): 19-23

ORIGINAL ARTICLE

Comparison of Epiretinal Membrane Peel
after Dual Staining Versus En Bloc Peel

Using Negative Staining Technique

Tehmina Jahangir
1
, Qasim Lateef Chaudhry

2
, Haroon Tayyab

1-2
Department of Ophthalmology, Allama Iqbal Medical College, Lahore,

3
Department of Ophthalmology, Mayo

Hospital, KEMU Lahore

ABSTRACT
Purpose: To compare the completeness of ILM peel in cases of Idiopathic Epiretinal Membranes following

double staining and double peeling versus en bloc dissection of both using negative staining method.

Study Design: Quasi experimental study.

Place and Duration of Study: Jinnah Hospital Lahore, from October 2017 to March 2018.

Material and Methods: Forty eyes of forty patients with Idiopathic Epiretinal membranes (ERM) were selected
by non-probability convenient method and divided into two groups. In group A, the ERM was initially stained with
Trypan blue and then peeled. Subsequently the macula was re-stained with Brilliant blue G (BBG). In group B,
ERM and ILM were successfully peeled together as a single membrane utilizing the single block technique, after a
desired negative staining effect was obtained by injecting BBG. The thoroughness of the ILM peel was
established using another injection of BBG although a few remains were often identified outside the central
macular area, no other dyes were used.

Results: In group A, 8 of the 20 eyes (40%) had full undisturbed ILM present whereas in 10 eyes (50%) the ILM
was there but damaged, only 2 eyes (10%) had near total ILM removed. In group B, the dual peeling was
successful in 17 of the 20 cases (85%). There has been no recurrence of ERM until now.

Conclusion: Instead of peeling twice, the single en bloc negative staining technique with Brilliant blue G is a
safer and more effective method for removal of ERM together with ILM.

Key Words: Pars plana vitrectomy, Epiretinal membrane, Internal limiting membrane.

How to Cite this Article: Jahangir T, Chaudhry QL, Tayyab H. Comparison of Residual Internal Limiting
Membrane Following Epiretinal Membrane Peel After Dual Staining Versus En Bloc Peel Using Negative Staining
Technique, Pak J Ophthalmol. 2020; 36 (1): 19-23.
DOI: https://doi.org/10.36351/pjo.v36i1.897

INTRODUCTION

Epiretinal membrane (ERM) is a disorder of the

vitreomacular interface and is used to describe a

condition in which there is cellular proliferation on the

inner retinal surface. Epiretinal membrane is a very

Address for Correspondence: Tehmina Jahangir

Assistant Professor Ophthalmology Department

Allama Iqbal Medical College, Lahore

E-mail: tehminajahangir@gmail.com

`
common finding in people over the age of 50 years.

The prevalence of Idiopathic ERM is 2% in people

younger than 60 years and approximately 12% in those

who are more than 70 years of age
1
. Most are

discovered incidentally during routine

ophthalmoscopic examination. Others become

symptomatic and require treatment. The standard of

treatment for a symptomatic ERM is its surgical

removal. Modern vitreoretinal techniques involve

small-gauge vitrectomy and the use of dyes to

https://doi.org/10.36351/pjo.v36i1.897

Comparison of Residual Internal Limiting Membrane Following Epiretinal Membrane Peel After Dual Staining Versus En Bloc Peel Using

Pakistan Journal of Ophthalmology, 2020, Vol. 36 (1): 19-23 20

facilitate the visualization of membrane
1
. Several

studies have advocated peeling of ILM during ERM

surgery to minimize the recurrence of ERM without

negatively affecting visual outcomes
2,3

. It has been

suggested that ILM removal per-operatively removes

the scaffolding for any fibroblast proliferation and

residual microscopic ERM, therefore diminishing the

risk of recurrence in addition to improving the final

visual outcomes
1
.

We conducted a prospective interventional study

to compare the completeness of ILM peel using two

different methods of ERM staining.

MATERIAL AND METHODS

We studied 40 consecutive patients (40 eyes), 22

males and 28 females who underwent surgery for

primary idiopathic epiretinal membrane over a period

of 6 months from October 2017 to March 2018. All

patients were followed up for ≥ 6 months after they

were enrolled in the study. All ophthalmic surgeries

were performed by one ophthalmic surgeon (XY) at

the Department of Ophthalmology, Jinnah Hospital,

Lahore. Patients with secondary ERM, presence of

glaucoma, retinal degeneration, optic neuropathy and

age less than 18 years were excluded from the study.

Approval for the study was obtained by the hospital

ethics committeeand informed consent was taken in

writing from all subjects.

A standard subtotal 23G 3-ports pars plana

vitrectomy (PPV) was performed using the Optikon

Pulsar 2 Vitrectomy system. The microscope in use

was Leica M844 F20 with its built-in RUV 800

viewing system.

In Group A, a standard 23G PPV was performed.

After performing core vitrectomy and inducing

posterior vitreous detachment, fluid air exchange was

done and ERM was stained with Trypan blue dye. The

fluid was reopened through the infusion cannula and

the stained ERM was peeled with 23G intraocular end-

gripping forceps. BBG (0.025%) was applied to the

peeled area (under air) for another one minute and the

extent of the residual ILM was noted. A second

peeling of the ILM was performed using ILM forceps

in all cases with residual ILM whether it was intact or

damaged.

In Group B, a standard 23G PPV was performed.

After core vitrectomy and induction of PVD, fluid air

exchange was done. We proceeded with a singular

technique of staining by introducing the BBG dye

0.025%, through either of the superior ports. The

injected dye was directed towards the macula but

injected in a very gentle manner while keeping a safe

distance. The dye was left in place under air for a

minute before reopening the fluid. Since BBG

primarily stains the ILM it did not stain the areas

concealed by the ERM. Therefore, in this group we

aimed to stain the ERM negatively while staining the

ILM directly, so the contrasting margins between the

unstained ERM and the stained ILM were clearly

distinguished thus achieving a negative staining effect

(fig. 1). With a 23 G ILM peeling forceps the ILM was

pinched and peeled temporally simultaneously double

peeling i.e., dragging enbloc the ERM and the

underlying ILM and in a single step in an annular

direction around the fovea (fig. 2). In almost all cases,

the peel was extended up to the temporal vascular

arcades releasing any centripetal and tangential

tractions along the way. We then reinjected the BBG

to re-stain the peeled area to confirm any residual ILM

requiring removal (fig. 3 and 4). All cases in both

groups were closed under SF6 tamponade.

All data was recorded on a predesigned proforma.

The data was entered and analyzed by SPSS (version

20) using the Chi Square test for statistical analysis

and results.

RESULTS

In group A, the ERM was initially stained with Trypan

blue, the ERM was peeled. Subsequently the macula

was re-stained with BBG. Eight of the 20 eyes (40%)

had full undisturbed ILM whereas in 10 eyes (50%)

the ILM was there but damaged, only 2 eyes (10%)

had near total ILM removed.

In group B, the dual peeling was successfully

performed in 17 of the 20 cases (85%) by utilizing the

en block technique, after successfully obtaining a

negative staining effect using BBG. The completeness

of ILM peel was established using an additional BBG

injection although some residual ILM was often

encountered further away from the central macular

area. No other dye was injected. There has been no

recurrence of ERM to date.

In either of the two groups there were no

significant complications related to peeling except for

a few superficial self-resolving retinal hemorrhages

and one case of small iatrogenic hole in the temporal

macula.

Jahangir T, et al

21 Pakistan Journal of Ophthalmology, 2020, Vol. 36 (1): 19-23

Fig. 1: Negative staining effect: the blue areas represent the
internal limiting membrane as stained with the Brilliant Blue
G dye; Areas devoid of the dye are covered with the
epiretinal membrane.

Fig. 2: Enbloc peeling: both the internal limiting membrane and the
epiretinal membrane are removed in a single step.

Fig. 3: Second time Brilliant Blue G dye injected near the macula.

All data was recorded on a predesigned proforma.

The data was entered and analyzed by SPSS (version

20).

Fig. 4: No residual Internal limiting membrane can be seen after en
bloc removal of both membranes in a single step.

DISCUSSION

ERM usually requires removal when it leads to

structural damage to the retina, an increase in macular

thickness or troublesome visual symptoms. Ideally the

surgery for ERM removal should both have a minimal

recurrence and little or no retinal trauma and

toxicity
4,5

. This can be accomplished by

simultaneously peeling the ILM and by using the least

toxic dye in as little a concentration as feasible.

The rate of ERM recurrence is lower when

combined with ILM peel
6
. The postoperative BCVA

or CMT is not influenced significantly by ILM peeling

which endorses the use of the surgical technique for

patients with ERM
7,8

. Moreover, ILM peeling has a

clear advantage of decreasing ERM recurrence
9,10

Although in 30 to 70% of patients, ILM is often

removed together with ERM, complete and sufficient

area of ILM peeling is essential to avoid ERM

recurrence
11

The technique of negative staining reported by

Foster et al
12

aimed to decrease injury to the retina and

increase visibility, by utilizing indocyanine green

(ICG) to preferentially stain the ILM surrounding the

margins of the ERM, although it lightly stained the

ERM as well. However, when selecting dyes that

preferentially stain the ILM, recent studies suggest that

BBG may be the least toxic, especially in comparison

to ICG
13,14

. Brilliant Blue G is a selective dye used to

stain the ILM on a stand-alone basis, with little to no

affinity for the ERM, and a suitable safety profile
15

Moreover, current evidence suggests that this dye may

also have a protective role against cell apoptosis
16

. The

Comparison of Residual Internal Limiting Membrane Following Epiretinal Membrane Peel After Dual Staining Versus En Bloc Peel Using

Pakistan Journal of Ophthalmology, 2020, Vol. 36 (1): 19-23 22

results of our study are comparable with those of

Carpentier et al and Shimada
2,3

Removal of the two membranes in a single step

has several advantages. It reduces the number of times

the retina is grasped as well as traction on the retinal

surface while simultaneously reducing the membrane

removal time and diminishing phototoxicity; all of

which are probable causes of iatrogenic damage to the

retina
17,18

Although the availability of stains for the ILM has

made peeling safer, the procedure is still not free of

complications. These include: retinal edema, nerve

fiber layer damage, retinal hemorrhages,

electrophysiological shifts and visual field changes

have all been documented after ILM peeling
19,20,21

The limitation of our study is the small sample

size. Research with large sample size and data from

different hospitals will be helpful in further proving

the results.

CONCLUSION

Instead of using two dyes for staining and peeling of

ERM twice, using a single en bloc technique is not

only less time-consuming but also safer in terms of

decreased exposure to dyes, reduction in grasping

attempts and overall reduced surgical time as well as

decreased phototoxicity.

Ethical Approval

The study was approved by the Institutional review

board/Ethical review board.

Conflict of Interest

Authors declared no conflict of interest

Authors’ Designation and Contribution

Tehmina Jahangir; Assistant Professor: Study design,

manuscript writing, literature review.

Qasim Latif Chaudhary; Associate Professor:

Literature review and final critical review.

Haroon Tayyab; Assistant Professor: Literature review

and final critical review.

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