OSLI Retina

October 2018

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October 2018 ยท Vol. 49, No. 10 789 brilliant blue G (BBG), and triamcinolone acetonide (TA); other dyes are also currently under investiga- tion. Trypan blue has been approved by the FDA for epiretinal membrane removal, and preservative-free triamcinolone acetonide has been approved by the FDA for intraocular use. The 2017 American Society of Retinal Specialists (ASRS) Preferences and Trends (PAT) survey demonstrated that of U.S. retina spe- cialists survey responders, 69.0% percent preferred to use ICG to aid in ERM and/or ILM peeling, 9.5% preferred TA, 14.8% used BBG, 1.2 % used TB, 3.1% preferred no dye, and 2.4% used an unlisted dye. 2 Additionally, the last decade has seen a trend toward more U.S. providers utilizing ICG despite some re- ports of toxicity, with a slight decrease in the use of TA and TB (Figure 1). 2-6 Of particular concern with chromovitrectomy dyes is the potential for acute and/or chronic toxic- ity to the neurosensory retina and retinal pigmented epithelium (RPE), and the toxicity of commonly used dyes is discussed throughout this text. Although most physicians peel the ILM during macular hole (MH) surgery due to the improvement in MH closure rates, the visual results of ILM peeling during ERM resec- tion are less convincing. Despite reducing the rate of recurrence of ERMs, ILM peeling has not convinc- ingly improved visual outcomes, and the recurrence rate of ERMs is already relatively low. 7 The potential for harmful effects, varied practice patterns, and other limitations highlight the need for a current literature review and further advancements. Historical Perspective: Introduction of ICG-Assisted ILM Peeling Surgical repair of idiopathic MHs has undergone significant evolution in the last three decades. In 1991, Kelly and Wendel published a technique for surgical closure in which pars plana vitrectomy (PPV) was combined with intraocular gas tamponade and face-down positioning. This procedure resulted in 58% MH closure rate and 42% improvement in visu- al acuity (VA), a tremendous improvement compared to observation. 8 During the ensuing decade, various modifications to this technique were investigated, with the goal of improving closure rates and visual outcomes. The technique that is currently popular involves removal of the ILM around the MH. It is hy- pothesized that ILM removal reduces tangential forces Figure 1. U.S. retina specialist internal limiting membrane (ILM) / epiretinal membrane (ERM) removal dye preference over time. The data, obtained from annual ASRS Preference and Trends Surveys, demonstrates an increasing popularity of ICG for ILM and / or ERM peeling during the last decade and a trend toward a decrease in the use of TA and TB. The data for this graph were obtained and used in this manuscript with permission from the ASRS. BBG = brilliant blue G; ICG = indocyanine green; TA = triamcinolone acetonide; TB = trypan blue. ASRS = American Society of Retina Specialists

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