In this video, we will see how reverse triamcinolone acetonide (TA) staining can be used to make internal limiting membrane (ILM) peeling, easier and safer. The ILM is the layer that borders the vitreous body and the retina, and also the basement membrane for the muller cells. It functions as the foothold for cell reproduction and is involved in macular diseases, such as epiretinal membrane or vitreo- macular traction. The expected advantage of removing the ILM with the epiretinal membrane is the possible mitigation therewith of the ‘traction’ applied on the retina, which will help prevent macular holes and a recurring epiretinal membrane. However, care should be taken in removing the ILM, as it may damage the neurosensory retinal layer. The ILM is a very thin and clear tissue that is difficult even for a skilled expert to identify. Indocyanine green (ICG) staining has been introduced as a solution to this problem. It has a major drawback, however–its side effects. The side effects of ICG include cell toxicity, photo toxicity, atrophy of the RPE, and residence of ICG pigments inside the eyeball for up to six months after the operation, which damages the sight and the field of view. To solve this problem, the reverse TA staining technique is used to assist with the removal of the ILM. Reverse triamcinolone staining is based on the characteristics of the triamcinolone particles that stick to the surface without the ILM after the epiretinal membrane is removed. In many cases, the ILM is removed along with the epiretinal membrane. When this happens, it is very difficult to find the remaining fractions of the ILM, as it is very clear and thin. However, with triamcinolone injected into the eyeball, the white particles of the chemical stick only to the parts of the retina not covered by the ILM. The particles also settle on the surface of the internal membrane, but do not adhere to it. They simply cover it with a thin layer. At this stage, the silicone tip canula can be used to remove the triamcinolone particles on the remaining pieces of the ILM. The particles on the retina without the internal membrane will stay there even after the canula is used, which makes it much easier to identify the areas still covered by the internal membrane. The reverse triamcinolone staining technique has other advantages. It does not have any form of cellular or photo toxicity. Otherwise, it does not stain the tissues inside the eyeball, as ICG does, which makes it easier to remove completely during an operation. Now, we will take a closer look at how reverse triamcinolone staining is used to remove the the ILM.

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Ji Hye Jang