Sir,
We appreciate the comments of Dr Soong and Mr Saha1 concerning our article.2 We reported a thinning of the ganglion cell complex (GCC) and a significant correlation between the thickness of GCC and retinal sensitivity measured by microperimetry after internal limiting membrane (ILM) peeling in eyes with an idiopathic macular hole (MH). We reported that the thinning of the GCC at 3 and 6 months after vitrectomy was significantly correlated with the reduced retinal sensitivity.2
As Dr Soong and Mr Saha suggested, the outer layer of the neurosensory retina can be damaged by peeling of ILM. The ILM is the endfeet of the Müller cells and the tractional force induced by ILM peeling might be transmitted to the other end of the Müller cells, where they are attached to the photoreceptors by intermediate junctions (zonulae adherentes). However, we did not observe any significant changes of the external limiting membrane by SD-OCT in the area where the ILM had been peeled.
Lois et al3 have reported a higher rate of anatomic closure and lower reoperation rates after ILM peeling in eyes with a MH in their multicenter randomized controlled trial. Their rate of reoperation was relatively high (12% in ILM-peeled eyes and 48% in non-ILM-peeled eyes), but they concluded that ILM peeling appeared to have beneficial effects. They concluded that ILM peeling was more cost-effective than no ILM peeling to treat stage 2 or 3 MHs (they excluded stage 1 and 4 MH).4 We agree that ILM peeling is beneficial to treat MHs but ILM peeling can be harmful to retina as we have reported. It was not our purpose of this study to prove that the ILM peeling is necessary to close MH but to show there were some negative aspects of ILM peeling. Our goal was to close the MH, and peeling the ILM led to better closure rates. However, further studies are needed to determine whether ILM peeling is necessary to close MH with various preoperative conditions, for example, different MH stages, diameters, duration from onset, and microstructures observed by SD-OCT.
References
Soong TK, Saha N . Comment on ‘Reduction of thickness of ganglion cell complex after internal limiting membrane peeling during vitrectomy for idiopathic macular hole’. Eye 2013; 27 (3): 455.
Baba T, Yamamoto S, Kimoto R, Oshitari T, Sato E . Reduction of thickness of ganglion cell complex after internal limiting membrane peeling during vitrectomy for idiopathic macular hole. Eye 2012; 26: 1173–1180.
Lois N, Burr J, Norrie J, Vale L, Cook J, McDonald A et al. Internal limiting membrane peeling versus no peeling for idiopathic full-thickness macular hole: a pragmatic randomized controlled trial. Invest Ophthalmol Vis Sci 2011; 52: 1586–1592.
Ternent L, Vale L, Boachie C, Burr JM, Lois N . Cost-effectiveness of internal limiting membrane peeling versus no peeling for patients with an idiopathic full-thickness macular hole: results from a randomized controlled trial. Br J Ophthalmol 2012; 96: 438–443.
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Baba, T., Yamamoto, S. Reply to Dr Soong and Mr Saha. Eye 27, 455–456 (2013). https://doi.org/10.1038/eye.2012.295
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DOI: https://doi.org/10.1038/eye.2012.295
