Iatrogenic punctate chorioretinopathy after internal limiting membrane peeling

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Abstract

Purpose

To define the chorioretinal lesions created unintentionally during grasping the internal limiting membrane (ILM) with end-gripping forceps.

Design

Interventional case series.

Methods

A prospective review of a consecutive series of 15 patients (15 eyes) who underwent macular hole repair was performed. All patients underwent a three-port pars plana vitrectomy with ILM peeling. Fundus photographs, fluorescein angiography, and indocyanine green angiography were performed in all patients before and after surgery.

Results

In all eyes, small punctate barely seen chorioretinal lesions in the macular region were detected after surgery. These punctate lesions corresponded to the area where ILM was grasped with forceps. The lesions ranged from 100 to 400 μm in diameter. Their number ranged between 8 and 15 (mean, 12.6). In the early phase of fluorescein angiography, the lesions appeared hypofluorescent; in the late phase, there was slight staining of the margin of the lesions extending from the adjacent choriocapillaris, causing indistinct borders. In the early phase of indocyanine green angiogram, the lesions were hypofluorescent and in some larger lesions choroidal vessels were visible due to the thinning and atrophy of the retinal pigment epithelium and choriocapillaris. In the late phase, the homogenous hypofluorescent areas had well-delineated margins and were usually round or oval. This angiographic finding was independent of the age of the lesion, and neither enlargement of the lesions nor development of choroidal neovascularization were noted during follow-up.

Conclusions

Iatrogenic punctate chorioretinopathy is the chorioretinal lesion created unintentionally during grasping the ILM with end-gripping forceps. It must be reported as one of the complications of ILM peeling. These small punctate lesions did not appear to affect the surgical outcome. However, the lesions should be followed to detect any long-term complication such as choroidal neovascularization.

Section snippets

Design

This study was done as an interventional case series.

Methods

During examination of patients who underwent macular hole surgery, some small, barely seen, chorioretinal lesions in the macular region were noticed. These lesions seemed to mimic other pathologic conditions such as multifocal choroiditis or punctate inner choroidopathy. To define these chorioretinal lesions, 15 eyes of 15 patients who underwent macular hole surgery with ILM peeling were followed prospectively.

Inclusion criteria included an unequivocal stage 3 or 4 macular hole, as determined

Results

Fifteen consecutive patients (15 eyes) were prospectively recruited. Patient demographics, diagnosis, and outcomes have been tabulated in Table 1. The mean follow-up period was 10.8 (±3.5) months (range, 6–16 months). The operations and postoperative periods were uneventful in all cases. No complications were seen in any patient. During follow-up in all eyes, small punctate, barely visible, chorioretinal lesions in the macular region were detected starting immediately after the gas tamponade

Discussion

Surgical removal or peeling of the ILM has been described as a potentially useful adjunct to vitreoretinal surgery particularly in selected macular hole cases.8, 11, 12 Internal limiting membrane peeling can be performed by making a small opening and a flap tear in the ILM with a bent microvitreal retinal blade. The ILM flap is then grasped with end-gripping forceps and carefully started in a circular capsulorhexis maneuver.7 In another technique of ILM peeling, the membrane can be removed by

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