Traction Maculopathy Terminology Macula Vision Test What to Expect Services Publications

  

"Here, at whatever hour you come, you will find light and hope and human kindness"
Retina Specialists of Alabama LLC

FIGURE 1 ( C) EMP AFTER CONTRACTION TO PRODUCE MACULAR PUCKER. ANALOGOUS TO A LINE OF MEN SHORTENING A ROPE (D).

FIGURE 2 (A) ABNORMAL GLIAL CELL MEMBRANES (G) ATTACHED TO THE MACULAR SURFACE (I = ILM) BEFORE CONTRACTION (R = RETINA). ANALOGOUS TO A LINE OF MEN HOLDING A ROPE (B).

FIGURE 3 FILMS CANNULA™ INSERTED UNDER SCARRED RETINAL SURFACE LAYER. GRADUAL INJECTION OF CLEAR, VISCOUS FLUID SEPARATES EMP / ILM COMPLEX FOR SUBSEQUENT EASY REMOVAL FROM THE EYE BY FORCEPS.

Medical information provided in this site is intended to assist you in understanding a complex condition. It can not replace the judgment and skill of your personal doctor.

NEI National Eye Institute
Resource Guide
for Macular Puker

Macula Disease

MACULAR PUCKER
MACULAR HOLE
CELLOPHANE MACULOPATHY
DIABETIC TRACTION MACULOPATHY
VITREOMACULAR TRACTION SYNDROME
      All are forms of traction maculopathy

Introduction
The vast majority of operations on the macula are performed to relieve traction on its surface (Figures 1). Such traction is usually the result of spontaneous aging changes or diabetic scarring. This surgery is common, highly successful, and has been available for more than twenty years, with significant improvement in the 1990's.

Less frequently, macular surgery is performed to treat aged related macular degeneration - a term commonly used to describe degenerative changes in the pigment and blood vessels beneath the macula. This surgery removes blood or abnormal blood vessels beneath the macula, or attempts to rotate the macula to overlie a healthier blood vessel layer. This surgery is relatively recent, is less successful, and is associated with greater risk.

Please see the Resources section for more information on the surgical treatment of age-related macular degeneration. Discussion is here confined to the surgical treatment of the various traction maculopathies affecting the macular surface. You may review the glossary of terms before proceeding, or consult the glossary as necessary during your reading.

"Aging" Traction Maculopathy
About 6% of persons over the age of 50 gradually accumulate some detectable scar tissue on the surface of the center of vision (the macula) (Figure 2). This tissue, appearing as a subtle "cobweb", is attached to the previously smooth and glistening macular surface (the internal limiting membrane, or ILM)

As cells float down to the macula from the vitreous cavity over a period of years, they attach to the ILM and then produce a substance called collagen that links them together in a "membrane" structure called epimacular proliferation (EMP). Cells reproduce (proliferate) and pull on the collagen, causing the ILM to wrinkle (Figure 2). This wrinkles or distorts images seen by the macula. Once the ILM is wrinkled, like crushed cellophane wrap, it will probably never be entirely smooth again (cellophane maculopathy).

Severe contraction of EMP may wrinkle most of the thickness of the macula causing macular pucker. Additionally, even modest proliferation on the ILM may expand a small defect in the fovea to produce a macular hole.

All this takes place in an area about one millimeter in size! That's the size of the center of vision. These changes involve both eyes in 10-30% of cases, and can even reduce visual acuity to the level of 20/200 or legal blindness.

Diabetic Traction Maculopathy
Diabetic macular disorders require surgery when traction forces applied to the macular surface by abnormal scar tissue are causing significant structural and/or functional changes. This usually takes the form of macular distortion or wrinkling, or even macular detachment, in proliferative diabetic retinopathy. Recently, credible investigators have shown substantial improvement of diffuse macular edema in non-proliferative (background) diabetic retinopathy with surgical release of even modest traction. This traction may be in the form of proliferation on the ILM (cellophane maculopathy) causing tangential forces, or anterior posterior (AP) forces caused by the pulling of the attached vitreous gel (VMTS).

Vitrectomy Surgery*
To reach the macula, the surgeon typically performs vitrectomy surgery. Using a light pipe, a clear fluid infusion line, and a vitreous cutter/aspirator, all about the size of a ball point pen refill, the vitreous is removed using microscopic visualization. The eye is kept inflated by liquid. Special care is taken to gently remove the clear vitreous that may remain attached to the macula (the cortical vitreous). Assuming no allergies to iodine, indocyanine green (ICG) dye is then typically instilled to colorize the macular surface ILM so as to substantially aid in subsequent dissection.

EMP is then removed with delicate forceps if a distinct EMP membrane is present (Figure 4). ICG dye can be re-injected to more fully demonstrate the distorted underlying ILM, and this layer may also be removed for complete traction release. It may also be possible to remove the EMP/ILM complex in a single sheet.

In macular hole surgery, EMP is usually subtle, requiring ILM removal for complete traction release. This promotes the best possible hole closure rate, and hole closure to the point of invisible edges post-operatively, in our opinion (Reference 1).

Diabetic scar tissue is first removed with a vitreous cutter and scissors until the remaining surface traction is minimized. The surgery then proceeds as discussed above.

*Developed by Dr. Robert Machemer in 1971

References:
1. "Internal limiting membrane removal in the management of full-thickness macular holes". Mester, V., Kuhn, F., American Journal of Ophthalmology 129: 769-777, 2000
2. "Retinal Folds and Hemorrhagic Macular Cysts in Terson's Syndrome," Morris, R., Kuhn, F., Witherspoon ,C.D. Ophthalmology 101:1, 1994.

Patient InfoFellowship Program |MaculaSurgery|
RSA Research|RSA Physicians|RSA Location|Resources

Contact us at 205-933-2625 or 800-292-8166
Web Master
rev.Oct 2008

Privacy Practices

This Site Contains Copyrighted Text And Graphics © Copyright 2008 Retina Specialists of Alabama, LLC Illustrations - © Steve Gordon.