The internal limiting membrane (ILM) is a thin, transparent, acellular membrane that forms the innermost boundary of the retina. ILM is the basal lamina of the inner retina, it is formed by the footplates of Müller cells and is composed of collagen fibers, glycosaminoglycans, laminin, and fibronectin. It has an important role in the early stages of retinal and optic nerve development, as a critical component of retinal histogenesis and optic axonal growth and navigation to the optic disc. However, in adults it’s function is not yet fully understood. ILM is the interface between the retina and vitreous and serves as a scaffold for cellular proliferation of myofibroblasts, fibrocytes, and retinal pigment epithelium cells, playing a role in the pathogenesis of vitreoretinal diseases. ILM peeling is a surgical technique commonly used today to treat various vitreoretinal disorders including vitreoretinal interface diseases (vitreomacular traction, macular holes, and epiretinal membranes), macular edema in diabetes and retinal vein occlusion, myopic macular retinoschisis and retinal detachment.

We review the indications to perform the internal limiting membrane peeling and discuss the thresholds and the alternatives.

Macular holes: Do you need to operate and peel the ILM in all cases? In which cases could we wait or treat with a different approach?

Vitreomacular tractions: Recently, with the introduction of ocriplasmin in clinical practice, there are many cases that can be solved with a single injection, and in well selected cases, we can achieve a high rate of release. Only unsuccessful cases need vitrectomy.

Epiretinal membranes (ERMs): Due to complications reported by many authors, such as dissociated optic nerve fiber layer, localized perimetric defects, and other anatomical and functional damage to the retina, we are concerned about peeling all cases. In selected cases, in which ERM might recur, such as secondary and recurrent ERMs, we must peel.

Myopic macular retinoschisis: Most authors suggest that in these cases the ILM peeling is key for the resolution.

Macular edema: In several cases of macular edema, mainly in diabetic patients, there is an anomalous vitreoretinal interface with thickened and taut posterior hyaloid membrane, exerting traction on the macula. In these cases, resolution of macular edema can only be achieved with vitreoretinal surgery and ILM peeling.

Retinal detachments: In our experience we think that in some cases, such as total retinal detachments involving the macula, and in cases of proliferative vitreoretinopathy, the ILM peeling is important. Nowadays, complete ILM peeling is not suitable for every type of macular surgery. The decision to peel the ILM should be individualized, based on the surgical situation.



Ophthalmology Department, Setubal Hospital Center
Setubal, Portugal
Email : drdavidmartins@hotmail.com
Cell Phone: +351964029156
Work Phone: +351964029156