Functional and morphological outcomes of En-bloc technique for removal of ERM-ILM complex in the management of idiopathic ERM

Functional and morphological outcomes of En-bloc technique for removal of ERM-ILM complex in the management of idiopathic ERM | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Functional and morphological outcomes of En-bloc technique for removal of ERM-ILM complex in the management of idiopathic ERM Wael Mohamed Soliman, Mohamed Sharaf Ghoneima, Zeiad Hasan Eldaly This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6507623/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background En-bloc removal of ILM-ERM complex provides a radical intervention that treats not only the ERM but also the underlying diseased ILM in one step ensuring complete removal of the ERM and preventing recurrence. The aim of the study is to investigate visual and macular structural and vascular perfusion changes after En-bloc removal of ERM-ILM complex for management of idiopathic ERM. Methods A prospective interventional study included patients with idiopathic ERM. PPV with removal of ERM and ILM as one unit (En-bloc removal) was performed. Structural OCT was used to classify ERMs according to EIFL stage, Enface OCT was used to demonstrate ERM effect on VMI and OCT-A to highlight vascular perfusion changes at baseline and 3 months post-operatively. Results Twenty-three patients were recruited for the study, 2 patients were excluded because of failure to perform En-bloc removal of ERM-ILM complex. A significant improvement in BCVA was noted at 3 months (0.35 ± 0.16, at 3 months vs 0.16 ± 0.08 at baseline, p-value: 0.005). Macular thickness decreased from 414.76 ± 63.22 to 336.95 ± 43.01 µm at 3 months (p-value: 0.005). Enface OCT revealed significant retinal folds in 16 eyes at baseline that disappeared after surgery in 14 out of 16 eyes. Retinal vascular wrinkling and straightening on OCT-A were significantly ameliorated after surgery with enhancement of vascular perfusion maps (vascular density at 1 mm 17.06 ± 1.59 at baseline and 24.13 ± 2.40 at 3 months (p-value; 0.013). Conclusion En-bloc removal of ERM-ILM complex provides satisfactory visual and macular morphological improvement. En-bloc Epiretinal membrane Internal limiting membrane peeling Vitrectomy Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Introduction Idiopathic epiretinal membrane (ERM) encompasses the proliferation of fibrous tissue along the vitreomacular interface in the macular region. The prevalence of idiopathic ERM increases up to 20% in patients older than 50 years whereas it decreases below 2% in patients younger than 50 years. ERM may be asymptomatic or visually significant. The patient may report detrimental symptoms in the form of metamorphopsia, micropsia, macropsia, or progressive visual impairment. 1 2 The effect of ERM on inner retinal layers was demonstrated in OCT and ectopic inner foveal layer (EIFL) was classified into four stages, ranging from stage 1 (ERM with preserved foveal depression) to stage 4 (ERM with lost foveal depression and distorted retinal architecture). 3 The effect of EIFL stage on the final visual outcome after surgical management has been discussed in different studies and the greater the stage is, the worse the visual outcome becomes. 4 5 Idiopathic ERM can be managed by different techniques including vitrectomy with ERM removal with or without Internal Limiting Membrane (ILM) peeling. Following surgical management for idiopathic ERM, functional visual recovery was achieved and retinal architecture was restored. 6 7 ILM peeling is considered a crucial step in the surgical management of idiopathic ERM. Vitrectomy with or without ILM peeling yielded comparable visual recovery and restoration of retinal architecture. However, higher rates of recurrence of ERM and increased incidence of redo vitrectomy has been reported in cases with no ILM peeling which favored the addition of ILM peeling in ERM management. 8 9 We will investigate the functional and architectural outcome of En-bloc excision of ERM-ILM complex altogether during vitrectomy for the management of idiopathic ERM. Methods Study design A prospective interventional study was conducted under the tenets of Helsinki declaration. The benefits and risks of the surgical technique were discussed and informed consents were signed. Approval of the Institutional Review Board of the Faculty of Medicine, Assiut University was fulfilled (IRB No 04-2024-300455). The current study was conducted in The Department of Ophthalmology, Assiut University Hospital, Egypt from August 2023 to September 2024. Participants The present study recruited 23 patients (23 eyes) suffering from idiopathic ERM with significant macular architectural changes (EIFL stage 2 or worse). Patients who had previously cataract surgery 6 months prior to study enrolment were included. The study excluded any participant with ERM secondary to co-existing retinal vascular disorders (e.g. diabetic retinopathy, retinal vascular occlusion), age-related macular degeneration (AMD), previous surgery for retinal detachment or diabetic vitreous hemorrhage, silicone-filled eyes, previous ocular trauma, previous retinal laser, intraocular inflammation or high myopia (axial length greater than 26 mm). Furthermore, patients with media opacity hindering adequate OCT acquisition scan signals were excluded. Intraoperatively, the inability to remove the ERM and ILM in one block and resort to double-peeling was also considered an exclusion criterion. Baseline assessment At the recruitment visit, all participants had a comprehensive ophthalmic assessment that included demographic data, medical and ocular history, Best corrected visual acuity (BCVA, Decimal notation), slit lamp examination, intraocular pressure (IOP) measurement via ICare rebound tonometer (ICare Oy, Helsinki, Finland), dilated fundus examination via + 78 D lens. OCT scan protocol After fulfilling inclusion criteria, OCT b-scans, 3D macular maps (Enface OCT), and OCT angiography (Triton Deep Range Imaging (DRI) OCT, Topcon Inc., Japan) were performed on all participants at baseline and 3 months postoperatively. OCT included 9X9 mm macular radial scans to evaluate the macular morphological changes as foveal contour, retinal folds, pseudohole, disorganization of internal retinal layers (DRIL), ellipsoid zone (EZ) disruption, external limiting membrane (ELM) disruption within 1 mm around the fovea, neurosensory detachment, macular thickness mapping (ETDRS 1,3,6 mm macular thickness map), and to determine the stage of idiopathic ERM according to EIFL classification. A-scans were performed at 70000 scans per second, with lateral resolution of 2 µm and in-depth resolution of 2.6 µm. Enface OCT (6X6 mm macular cube) was used to assess vascular wrinkling or straightening, retinal folds, and epicenter formation. Moreover, OCT angiography was used to delineate qualitative changes in superficial capillary plexus (vascular wrinkling and straightening) as well as quantitative changes (FAZ area and vascular density map) in the central 6X6 mm cube. Surgical intervention The participants underwent 25 G vitrectomy (Stellaris Elite™, Bausch + Lomb Corp., USA) with en-bloc removal of ERM-ILM complex. Patients with significant cataract underwent combined phacoemulsification-vitrectomy to enhance visualization of the macular region and to ensure controlled manipulation over the macula. Three standard 25 G sclerotomies were performed initially followed by core vitrectomy and induction of posterior vitreous detachment (PVD). Negative staining of ERM was done using Brilliant Blue dye to stain the ILM and areas of attached ERM appeared as no-staining areas. Removal of the ERM-ILM complex started as ILM peeled beyond the extent of ERM borders, with no direct attempts to remove the ERM. After the initial punching of the ILM, meticulously grasping the ILM toward the area of ERM was commenced to ensure complete En-bloc removal of ERM-ILM complex without shredding the ILM. After En-bloc removal of ERM-ILM complex, re-staining was performed using Brilliant Blue dye to delineate the area of the peeled complex and ensure complete removal. An additional movie file shows this in more detail [see Additional file 1]. Postoperative medications included topical Moxifloxacin eye drops and topical Tobramycin-Dexamethasone eye drops, and tapering of eyes drops was scheduled according to physician discern. OCT scans were repeated 3 months after surgery along with BCVA assessment. Statistical analysis Data were collected and analyzed with SPSS v 20.0 for windows. Numerical data were presented as means and standard deviations (SD) whereas categorical data were presented as frequencies and percentages. A p-value of less than 0.05 was used to indicate statistical significance. Results Twenty-three subjects (23 eyes), 14 males and 9 females with mean age of 61.52 ± 4.6 years were recruited in the study. Baseline BCVA was 0.16 ± 0.08, IOP was 15.09 ± 2.36, and mean spherical equivalent was −2.15 ± 1.73 diopters. At the time of surgery, 18 patients (80.9%) were phakic and 5 patients were pseudophakic (19.1%). In the phakic group, there was a visually significant cataract in 3 patients who planned to have combined phacoemulsification and IOL implantation with the vitrectomy surgery. Failure of En-bloc removal of ERM-ILM complex was encountered in 2 patients who were excluded from the study. Tables 1 and 2 demonstrate demographic data and baseline evaluation of the participants. Functional visual outcome Postoperative mean BCVA improved significantly as compared with the baseline BCVA (0.35 ± 0.16 post-operatively vs 0.16 ± 0.08 at baseline, p-value: 0.005). At the 3 months postoperative visit, 18 subjects had improved in BCVA (85.7%), 2 remained stable (9.5%), and 1 patient had deteriorated of BCVA (4.8%). Macular morphological changes by OCT There were significant macular thickness and architectural changes after the En-bloc removal of ERM-ILM complex. Macular thickness improved from 414.76 ± 63.22 µm at baseline to 336.95 ± 43.01 µm at 3 months postoperatively (p-value: 0.005). Changes of foveal contour (either flat or preserved foveal depression as compared to convex configuration at baseline) after En-bloc removal of ERM-ILM complex was observed in 15 patients (15/21, 81.6%) by OCT at 3 months visit as compared with 7 patients (7/21, 33.3%) at baseline. Table 2 presents the macular morphological changes from baseline to 3 months follow-up visit. (Figures 1 and 2) Enface OCT changes Enface OCT revealed retinal folds in 16 patients (16/21, 80.1%) at baseline evaluation. (Table 1) Retinal folds manifested on Enface OCT as alternating white and black striation of the retinal surface related to tangential VMT exerted by the ERM. Three months postoperatively, retinal folds disappeared in 14 patients (14/16, 87.5%) and persisted in only 2 patients after En-bloc removal of ERM-ILM complex. (Figures 3 and 4) Vascular density and FAZ changes by OCT Angiography OCT angiography of SCP revealed vascular wrinkling in 19 patients (19/21, 95.5%) and vascular straightening in 17 patients (17/21, 89.5%) at baseline. Three months after surgery, vascular wrinkling and straightening improved as documented in Table 2. Furthermore, vascular density at 1 mm was improved from 17.06 ± 1.59 at baseline to 24.13 ± 2.40 at 3 months follow up (p-value; 0.013). On the other hand, the FAZ area at SCP decreased post-operatively from 255.57 ± 44.61 µm 2 to 198.05 ± 46.86 µm 2 (p-value; 0.001). Moreover, a reduction in FAZ area correlated well with improved VD (r; 0.281, p-value; 0.042). (Figures 5 and 6) Discussion Pars plana vitrectomy with ERM removal is the gold standard management of idiopathic ERM in symptomatic patients. However, the implementation of ILM peeling for ERM surgical management is debatable. Pathologically, ILM peeling will prevent the recurrence of fibroblast proliferation over the macular region as these cells are not able to proliferate in the absence of an ILM scaffold, thus theoretically preventing the recurrence of ERM formation. 10 11 Moreover, many studies have suggested that ERM formation is associated with pathological ILM, and that the removal of this pathological ILM would reduce the incidence of ERM recurrence. 12 13 In several studies, vitrectomy for idiopathic ERM first involved ERM removal via negative staining followed by staining and peeling of ILM in 2 separate steps. 14 15 16 In the present study, we investigated the “En-bloc” removal of ERM-ILM complex to remove the ERM completely as well as the pathological ILM in a single step. En-bloc removal of ERM-ILM complex does not differ from standard steps of ILM peeling as it only starts the ILM peeling in the area beyond the borders of ERM after staining with no specific surgical learning curve. In the present study, not only the macular thickness but also the macular morphology improved after En-bloc removal of ERM-ILM complex. CMT significantly improved postoperatively from 414.76 µm at baseline to 336.95 µm after 3 months and foveal contour was restored in 81.6% of patients. Macular morphological and perfusion improvements were reflected in BCVA as BCVA significantly improved after En-bloc removal of ERM-ILM complex from 0.16 at baseline to 0.35 at 3 months (p-value: 0.005) and visual improvement was documented in 85.7% of patients. Schechet et al. retrospectively evaluated patients who had vitrectomy for ERM removal with and without ILM peeling and investigated the difference in BCVA, CMT, and ERM recurrence. 17 They concluded that there was no significant difference in final BCVA or CMT. However, recurrence of ERM was detected in 22.9% of patients who didn’t have ILM peeling and nearly half of them needed another surgery for recurrent ERM. This study highlighted the potential benefit of ILM peeling to prevent ERM recurrence as we proposed in the current study. In contrast to the current study, Lee and Kim reported that patients who had ILM peeling exhibited higher CMT and less restoration of foveal contour (42.9%) compared to the non-peeling group (84.2%) but these differences were insignificant. 18 Mean reduction in CMT in ILM peeling group and the current study was similar (74.2 µm and 77.8 µm respectively). However, in the current study, 81.6% of patients had restored foveal contour compared previous study. Ahn et al. had a similar result when they compared patients with ERM with additional ILM peeling or not. They found that patients who had ILM peeling had worse BCVA than non-peeling at 1 month follow-up. 19 However, after one year follow-up, there was no significant difference between peeling and non-peeling groups regarding the final visual outcome or ERM recurrence rate. A variable percentage of ERM recurrences were reported even in patients who had ILM peeling. Obata et al. reported that the recurrence of ERM over 1 year was higher and significant in the non-ILM peeling group than ILM peeling group (20.5% and 42.6% respectively). Park et al. reported that none of the patients who had ILM peeling had recurrent ERM compared to 21% of patients who didn’t have ILM peeling. 20 Fleissig et al. reported that the incidence rate of recurrent ERM 5 years after ERM removal without ILM peeling is approximately 58%. 21 Several studies have investigated quantitative and qualitative macular changes after ERM removal via enface OCT and OCT angiography. In the present study, enface OCT highlighted retinal folds secondary to tangential traction exerted on the macular surface by ERM in 16 patients (80.1%). After surgery, retinal folds disappeared in 14 out of 16 patients (87.5%) at 3 months follow up. This finding was also emphasized by the improvement in vascular wrinkling and straightening documented by enface OCT from 19 and 17 out of 21 patients pre-operatively to 11 and 8 out of 21 patients in 3 months follow-up visits respectively. (Table 2 ). Furthermore, OCT angiography revealed improved macular perfusion in terms of increased vascular density (17.06 at baseline to 24.13 at 3 months, p-value; 0.003) and reduced FAZ area (255.57 µm 2 at baseline to 198.05 µm 2 at 3 months, p-value; 0.001). Ulfik-Dembska et al. reported that FAZ area was negatively correlated with CMT in patients with ERM. 22 Mao et al. investigated the effect of ERM surgery with ILM peeling on FAZ parameters and vascular density. 23 In contrast to the current study, they reported that there was a minimal change in FAZ area with a reduction in foveal vascular density despite the significant improvement in final visual acuity at the final visit. Bacherini et al. highlighted OCT angiographic changes after ERM removal and ILM peeling. VD increased significantly 6 months after surgery, however, FAZ area increased 6 months after surgery, in contrast to our study. 24 Muller et al. reported absence of any difference in FAZ area or vascular density between ERM surgery with or without ILM peeling. 25 To our knowledge, this is the first study to address the technique of En-bloc removal of ERM-ILM complex for the management of idiopathic ERM. The limitations of the present study include small number of participants and short-term follow-up. Further long-term comparative studies should be initiated to confirm the advantages of this technique. Conclusion En-bloc removal of ERM-ILM complex is a promising technique for the management of idiopathic ERM. Compared with non-ILM peeling techniques, it provides not only satisfactory visual gain but also macular morphological and vascular prefusion improvement with lower rates of ERM recurrence. Declarations Conflict of interest No conflicts of interest to disclose Funding and grants No funding or grants were obtained Author Contribution W.S. performed the surgery, did follow up for our patientsM.S. did OCT & OCTA and interpret imagesZ.E wrote the main manuscript, did statistics and discussionAll authors reviewed the manuscript Acknowledgement No acknowledgement to declare Data availability The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. References Fraser-Bell S, Guzowski M, Rochtchina E, et al. Five-year cumulative incidence and progression of epiretinal membranes: the Blue Mountains Eye Study. Ophthalmology. 2003;110(1):34–40 Xiao W, Chen X, Yan W, et al. Prevalence and risk factors of epiretinal membranes: a systematic review and meta-analysis of population-based studies. BMJ Open. 2017;7(9):e014644. Doguizi S, Sekeroglu MA, Ozkoyuncu D, et al. Clinical significance of ectopic inner foveal layers in patients with idiopathic epiretinal membranes. Eye (Lond). 2018;32(10):1652–1660. González-Saldivar G, Berger A, Wong D, et al. Ectopic inner foveal layer classification scheme predicts visual outcomes after epiretinal membrane surgery. Retina. 2020 ;40(4):710–717. Mavi Yildiz A, Avci R, Yilmaz S. The predictive value of ectopic inner retinal layer staging scheme for idiopathic epiretinal membrane: surgical results at 12 months. Eye (Lond). 2021;35(8):2164–2172. Matoba R, Morizane Y. Surgical Treatment of Epiretinal Membrane. Acta Med Okayama. 2021;75(4):403–413. Nam SW, Byun Z, Ham DI, Kong M. Microperimetric evaluation for different methods of epiretinal membrane surgery. BMC Ophthalmol. 2023;23(1):295. Told R, Georgopoulos M, Reiter GS, et al. Intraretinal microvascular changes after ERM and ILM peeling using SSOCTA. PLoS One. 2020;15(12):e0242667. Fung AT, Galvin J, Tran T. Epiretinal membrane: A review. Clin Exp Ophthalmol. 2021;49(3):289–308. Sivalingam A, Eagle RC Jr, Duker JS, et al. Visual prognosis correlated with the presence of internal-limiting membrane in histopathologic specimens obtained from epiretinal membrane surgery. Ophthalmology 1990;97:1549–1552. Gaudric A, Fardeau C, Goberville M, et al. Ablation of the internal limiting membrane, macular unfolding and visual outcome in surgery of idiopathic epimacular membranes. J Fr Ophtalmol 1993;16:571–576 Bovey EH, Uffer S, Achache F. Surgery for epimacular membrane: impact of retinal internal limiting membrane removal on functional outcome. Retina 2004;24:728–735. Sandali O, El Sanharawi M, Basli E, et al. Epiretinal membrane recurrence: incidence, characteristics, evolution, and preventive and risk factors. Retina 2013;33:2032–2038. Sultan H, Wykoff CC, Shah AR. Five-Year Outcomes of Surgically Treated Symptomatic Epiretinal Membranes With and Without Internal Limiting Membrane Peeling. Ophthalmic Surg Lasers Imaging Retina. 2018;49(5):296–302. Obata S, Fujikawa M, Iwasaki K, et al. Changes in Retinal Thickness after Vitrectomy for Epiretinal Membrane with and without Internal Limiting Membrane Peeling. Ophthalmic Res. 2017;57(2):135–140. Chang S. Controversies regarding internal limiting membrane peeling in idiopathic epiretinal membrane and macular hole. Retina 2012;32:S200–S203; discussion S3–S4. Schechet SA, DeVience E, Thompson JT. The effect of internal limiting membrane peeling on idiopathic epiretinal membrane surgery, with a review of the literature. Retina. 2017;37(5):873–880. Lee JW, Kim IT. Outcomes of idiopathic macular epiretinal membrane removal with and without internal limiting membrane peeling: a comparative study. Jpn J Ophthalmol. 2010;54(2):129–134. Ahn SJ, Ahn J, Woo SJ, Park KH. Photoreceptor change and visual outcome after idiopathic epiretinal membrane removal with or without additional internal limiting membrane peeling. Retina. 2014;34(1):172–181. Park DW, Dugel PU, Garda J, et al. Macular pucker removal with and without internal limiting membrane peeling: pilot study. Ophthalmology 2003;110:62–64. Fleissig E, Zur D, Moisseiev E, et al. Five-year follow up after Epi-retinal membrane surgery: A Single-Center Experience. Retina. 2018;38(7):1415–1419. Ulfik-Dembska K, Teper S, Dembski M, et al. Idiopathic Epiretinal Membrane: Microvasculature Analysis with Optical Coherence Tomography and Optical Coherence Tomography Angiography. Tomography. 2022;8(1):189–199. Mao J, Xu Z, Lao J, et al. Assessment of macular microvasculature features before and after vitrectomy in the idiopathic macular epiretinal membrane using a grading system: An optical coherence tomography angiography study. Acta Ophthalmol. 2021;99(7):e1168-e1175. Bacherini D, Dragotto F, Caporossi T, et al. The Role of OCT Angiography in the Assessment of Epiretinal Macular Membrane. J Ophthalmol. 2021;2021:8866407. Muller YG, Soudier G, Olteanu S, Lenoble P. Effets du pelage de la membrane limitante interne sur la microvascularisation maculaire en OCT-angiographie dans la chirurgie des membranes épirétiniennes [Effects of internal limiting membrane peeling in epiretinal membrane surgery on OCT-angiography]. J Fr Ophtalmol. 2023;46(8):896–907. Tables Table 1: Demographic data and ophthalmic assessment of study participants. Age (mean ± SD, years) 61.52 ± 4.6 Gender (M/F) 14/7 Lens status (n, %) Phakic Pseudophakic (17, 80.9%) (4, 19.1%) Mean spherical equivalent (mean ± SD, diopters) −2.15 ± 1.73 Pre-BCVA (mean ± SD, Decimal) 0.16 ± 0.08 Post-BCVA (mean ± SD, Decimal) 0.35 ± 0.16 IOP (mean ± SD, mmHg) 15.09 ± 2.36 CMT at 1 mm (mean ± SD, um) 414.76 ± 63.22 EIFL (n, %) Stage 1 Stage 2 Stage 3 Stage 4 (0, 0) (7, 33.3%) (9, 42.9%) (5, 23.8%) DRIL Present Absent 4 17 EZ disruption Present Absent 5 16 ELM disruption Present Absent 7 14 NSD Present Absent 2 19 BCVA; Best-corrected visual acuity, CMT; Central macular thickness, DRIL; Disorganized inner retinal layers, EIFL; Ectopic inner foveal layers, ELM, External limiting membrane, EZ; Ellipsoid zone, FAZ, Foveal avascular zone, IOP; Intra-ocular pressure, NSD; Neuro-sensory detachment Table 2: Comparison between pre- and post-operative retinal morphological and vascular perfusion changes by OCT and OCT Angiography Retinal architectural changes Baseline 3 months Post-operative OCT Foveal contour Preserved Flat Convex 1 6 14 4 11 6 Pseudo-hole Present Absent 5 16 1 20 CMT 1 mm (um) 414.76 336.95 En-face OCT Retinal folds Present Absent 16 5 2 19 OCT Angiography Vascular wrinkling Present Absent 19 2 11 10 Vascular straightening Present Absent 17 4 8 13 FAZ area (SCP) 255.57 198.05 VD 17.06 24.13 CMT; Central macular thickness, FAZ, Foveal avascular, OCT; Optical Coherence Tomography, SCP; Superficial capillary plexus, VD; Vascular density. Additional Declarations No competing interests reported. Supplementary Files EnBlocILMERMcomplexremoval.mp4 Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6507623","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":448587389,"identity":"7b754b37-e59d-4fec-bb51-c9b3de8d17ce","order_by":0,"name":"Wael Mohamed Soliman","email":"","orcid":"","institution":"Assiut University","correspondingAuthor":false,"prefix":"","firstName":"Wael","middleName":"Mohamed","lastName":"Soliman","suffix":""},{"id":448587390,"identity":"50c82a5a-b240-4bf0-9108-168eeb3b7db6","order_by":1,"name":"Mohamed Sharaf Ghoneima","email":"","orcid":"","institution":"Assiut University","correspondingAuthor":false,"prefix":"","firstName":"Mohamed","middleName":"Sharaf","lastName":"Ghoneima","suffix":""},{"id":448587391,"identity":"ab73981b-8834-45d8-b637-886e15315914","order_by":2,"name":"Zeiad Hasan Eldaly","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFklEQVRIie3Qv0vDQBTA8RcD1+WSrCmi/guRgCCR+K+848AsDo4FCz0QbvQvCP4NcVHcrhy0S3EWusTFKUNcSqfqRfHHciWj4H0hxyXw4T0C4HL9xZR5EHwIAT0Fo8+PcS9CzKlg0ZfAF/FkDxIuld/W42yfDHitg5uc3YM/XVI4yYWFDB8REpwVKaEviQ7uOHsQhGcUzriNJGZ7RKKZjLEjPqsUPdqloLltsY4o3OiJjItWB+XEkGhlyNs24gkmNZL43EwRuptCDFG5jQwX5m+x6+JQ0uZiWs7maaVJelwmHG0kNOR1vcoOokFxWzfjy71qfvX81IzyUxsBiNrv6w7tTv9jYWDCbn7y1r9etkxxuVyuf9Y7xt5YcJCGQHYAAAAASUVORK5CYII=","orcid":"","institution":"Assiut University","correspondingAuthor":true,"prefix":"","firstName":"Zeiad","middleName":"Hasan","lastName":"Eldaly","suffix":""}],"badges":[],"createdAt":"2025-04-22 23:53:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6507623/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6507623/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82122386,"identity":"adc717c4-1ecf-4083-b903-8cd95974c3c8","added_by":"auto","created_at":"2025-05-07 03:28:46","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":2212648,"visible":true,"origin":"","legend":"\u003cp\u003eB-scan OCT of the patient with a grade 4 idiopathic ERM (A) showing loss of foveal depression with macular thickening by a thick ERM. Ectopic foveal tissue is observed traversing the foveal center with retinal layer changes in the form of infoldings of the INL and OPL, and narrowing of the ONL with multiple cysts. (B) The postoperative image after membrane peeling reveals restoration of layers arrangement, absence of cysts, with irregular outline of the EZ at the fovea together with significant reduction of the central subfield foveal thickness.\u003c/p\u003e","description":"","filename":"Figure17.png","url":"https://assets-eu.researchsquare.com/files/rs-6507623/v1/aaf2371cd1f3d94de6aacb02.png"},{"id":82122389,"identity":"e59cbeb3-d168-4547-95df-db6491fa7142","added_by":"auto","created_at":"2025-05-07 03:28:47","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":2249946,"visible":true,"origin":"","legend":"\u003cp\u003eB-scan OCT of Patient 2 with Grade 4 idiopathic ERM and 3 months postoperatively reveals a decrease in the central subfoveal thickness despite persistent foveal elevation, straightening of vitreomacular interface and the inner retinal layers with better demarcation of layers boundaries , absence of the ectopic foveal layer and foveal cysts, better delineation of the subfoveal ELM and EZ.\u003c/p\u003e","description":"","filename":"Figure25.png","url":"https://assets-eu.researchsquare.com/files/rs-6507623/v1/1257a1e2d286d1e82290e002.png"},{"id":82122390,"identity":"1e88bda5-a22e-4438-854a-a647ca0520d6","added_by":"auto","created_at":"2025-05-07 03:28:47","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":3057909,"visible":true,"origin":"","legend":"\u003cp\u003eA 54 year-old male complained of progressive blurring of vision and metamorphopsia in right eye. Color fundus, Enface OCT, and OCTA of idiopathic ERM shows: \u003cstrong\u003eA\u003c/strong\u003e Preoperative fundus imaging revealed that epi-macular membrane extended between the arcades causing vascular distortion and foveal pit masking. \u003cstrong\u003eB \u003c/strong\u003eThree months postoperative imaging revealed vascular remodeling and foveal pit reappearance. \u003cstrong\u003eC \u003c/strong\u003e\u0026amp; \u003cstrong\u003eD \u003c/strong\u003eEnface OCT images was acquired at the level of the vitreomacular interface before and after membrane peeling respectively. \u003cstrong\u003eE \u003c/strong\u003e\u0026amp; \u003cstrong\u003eD \u003c/strong\u003ePre and post OCTA at the superficial vascular plexus demonstrated the vascular changes in the form of decreased vessel tortuosity, FAZ area changes with straightening of the parafoveal vessels.\u003c/p\u003e","description":"","filename":"Figure32.png","url":"https://assets-eu.researchsquare.com/files/rs-6507623/v1/a300a77831c3883f6d268caf.png"},{"id":82122388,"identity":"5ee12f94-deea-4267-b591-7c24448dd81e","added_by":"auto","created_at":"2025-05-07 03:28:47","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":826497,"visible":true,"origin":"","legend":"\u003cp\u003eColor fundus, Enface OCT, and OCTA images of idiopathic ERM before and 3 months after surgery. \u003cstrong\u003eA\u003c/strong\u003e Preoperative color photo demonstrated the epiretinal greyish membrane causing dragging of the macular vessels towards the fovea and obscuring the foveal pit with a spot of retinal hemorrhage. \u003cstrong\u003eB \u003c/strong\u003ePostoperative fundus picture revealed the repositioning of the macular vessels to their normal course and foveal pit appearance. \u003cstrong\u003eC \u003c/strong\u003e\u0026amp; \u003cstrong\u003eD \u003c/strong\u003eEnface OCT images was acquired at the level of the vitreomacular interface before and after membrane peeling respectively. \u003cstrong\u003eE \u003c/strong\u003e\u0026amp; \u003cstrong\u003eD \u003c/strong\u003ePre and post OCTA at the superficial vascular plexus demonstrated the vascular changes in the perifoveal region with restoration of their normal course with repositioning of the FAZ.\u003c/p\u003e","description":"","filename":"Figure44.png","url":"https://assets-eu.researchsquare.com/files/rs-6507623/v1/7a926dc3e0a602b588335b9b.png"},{"id":82123931,"identity":"c04933de-4450-4256-b1ab-f928559cc58a","added_by":"auto","created_at":"2025-05-07 03:36:47","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":3553626,"visible":true,"origin":"","legend":"\u003cp\u003eOCT angiography 4.5 × 4.5 mm images at the level of the superficial capillary plexuses before (A) and After (B) membrane peeling revealed the FAZ changes in the form of a decrease in FAZ diameter, and an increase in vascular density in the central 1mm area.\u003c/p\u003e","description":"","filename":"Figure51.png","url":"https://assets-eu.researchsquare.com/files/rs-6507623/v1/e42f50a0afcfa62a734a637c.png"},{"id":82123934,"identity":"d5796f1e-dc40-4335-9e27-a789f6176d28","added_by":"auto","created_at":"2025-05-07 03:36:47","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":3456932,"visible":true,"origin":"","legend":"\u003cp\u003eOCT angiography 4.5 × 4.5 mm images at the level of the superficial capillary plexuses before (A) and After (B) membrane peeling demonstrated the FAZ changes in the form of a decrease of the FAZ diameter, and an increase in vascular density in the central 1mm area.\u003c/p\u003e","description":"","filename":"Figure61.png","url":"https://assets-eu.researchsquare.com/files/rs-6507623/v1/ecb30580ed3e3874abef15d7.png"},{"id":92279349,"identity":"d5d17839-9d3b-4dc1-be09-9567a9619185","added_by":"auto","created_at":"2025-09-26 16:01:59","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":14782731,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6507623/v1/d8c46a02-4130-41b0-a62f-6589dcaaa618.pdf"},{"id":82123935,"identity":"49c2d796-da45-419b-bd0d-cb5ffc99924a","added_by":"auto","created_at":"2025-05-07 03:36:47","extension":"mp4","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":31900395,"visible":true,"origin":"","legend":"","description":"","filename":"EnBlocILMERMcomplexremoval.mp4","url":"https://assets-eu.researchsquare.com/files/rs-6507623/v1/8c5cc02237e558e91751e1fc.mp4"}],"financialInterests":"No competing interests reported.","formattedTitle":"Functional and morphological outcomes of En-bloc technique for removal of ERM-ILM complex in the management of idiopathic ERM","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIdiopathic epiretinal membrane (ERM) encompasses the proliferation of fibrous tissue along the vitreomacular interface in the macular region. The prevalence of idiopathic ERM increases up to 20% in patients older than 50 years whereas it decreases below 2% in patients younger than 50 years. ERM may be asymptomatic or visually significant. The patient may report detrimental symptoms in the form of metamorphopsia, micropsia, macropsia, or progressive visual impairment.\u003csup\u003e1\u003c/sup\u003e\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe effect of ERM on inner retinal layers was demonstrated in OCT and ectopic inner foveal layer (EIFL) was classified into four stages, ranging from stage 1 (ERM with preserved foveal depression) to stage 4 (ERM with lost foveal depression and distorted retinal architecture). \u003csup\u003e3\u003c/sup\u003e The effect of EIFL stage on the final visual outcome after surgical management has been discussed in different studies and the greater the stage is, the worse the visual outcome becomes. \u003csup\u003e4\u003c/sup\u003e\u003csup\u003e5\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIdiopathic ERM can be managed by different techniques including vitrectomy with ERM removal with or without Internal Limiting Membrane (ILM) peeling. Following surgical management for idiopathic ERM, functional visual recovery was achieved and retinal architecture was restored. \u003csup\u003e6\u003c/sup\u003e\u003csup\u003e7\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eILM peeling is considered a crucial step in the surgical management of idiopathic ERM. Vitrectomy with or without ILM peeling yielded comparable visual recovery and restoration of retinal architecture. However, higher rates of recurrence of ERM and increased incidence of redo vitrectomy has been reported in cases with no ILM peeling which favored the addition of ILM peeling in ERM management.\u003csup\u003e8\u003c/sup\u003e\u003csup\u003e9\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eWe will investigate the functional and architectural outcome of En-bloc excision of ERM-ILM complex altogether during vitrectomy for the management of idiopathic ERM.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eA prospective interventional study was conducted under the tenets of Helsinki declaration. The benefits and risks of the surgical technique were discussed and informed consents were signed. Approval of the Institutional Review Board of the Faculty of Medicine, Assiut University was fulfilled (IRB No 04-2024-300455). The current study was conducted in The Department of Ophthalmology, Assiut University Hospital, Egypt from August 2023 to September 2024.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eThe present study recruited 23 patients (23 eyes) suffering from idiopathic ERM with significant macular architectural changes (EIFL stage 2 or worse). Patients who had previously cataract surgery 6 months prior to study enrolment were included.\u003c/p\u003e \u003cp\u003eThe study excluded any participant with ERM secondary to co-existing retinal vascular disorders (e.g. diabetic retinopathy, retinal vascular occlusion), age-related macular degeneration (AMD), previous surgery for retinal detachment or diabetic vitreous hemorrhage, silicone-filled eyes, previous ocular trauma, previous retinal laser, intraocular inflammation or high myopia (axial length greater than 26 mm). Furthermore, patients with media opacity hindering adequate OCT acquisition scan signals were excluded. Intraoperatively, the inability to remove the ERM and ILM in one block and resort to double-peeling was also considered an exclusion criterion.\u003c/p\u003e\n\u003ch3\u003eBaseline assessment\u003c/h3\u003e\n\u003cp\u003eAt the recruitment visit, all participants had a comprehensive ophthalmic assessment that included demographic data, medical and ocular history, Best corrected visual acuity (BCVA, Decimal notation), slit lamp examination, intraocular pressure (IOP) measurement via ICare rebound tonometer (ICare Oy, Helsinki, Finland), dilated fundus examination via +\u0026thinsp;78 D lens.\u003c/p\u003e\n\u003ch3\u003eOCT scan protocol\u003c/h3\u003e\n \u003cp\u003eAfter fulfilling inclusion criteria, OCT b-scans, 3D macular maps (Enface OCT), and OCT angiography (Triton Deep Range Imaging (DRI) OCT, Topcon Inc., Japan) were performed on all participants at baseline and 3 months postoperatively. OCT included 9X9 mm macular radial scans to evaluate the macular morphological changes as foveal contour, retinal folds, pseudohole, disorganization of internal retinal layers (DRIL), ellipsoid zone (EZ) disruption, external limiting membrane (ELM) disruption within 1 mm around the fovea, neurosensory detachment, macular thickness mapping (ETDRS 1,3,6 mm macular thickness map), and to determine the stage of idiopathic ERM according to EIFL classification. A-scans were performed at 70000 scans per second, with lateral resolution of 2 \u0026micro;m and in-depth resolution of 2.6 \u0026micro;m. Enface OCT (6X6 mm macular cube) was used to assess vascular wrinkling or straightening, retinal folds, and epicenter formation. Moreover, OCT angiography was used to delineate qualitative changes in superficial capillary plexus (vascular wrinkling and straightening) as well as quantitative changes (FAZ area and vascular density map) in the central 6X6 mm cube.\u003c/p\u003e\n\u003ch3\u003eSurgical intervention\u003c/h3\u003e\n\u003cp\u003eThe participants underwent 25 G vitrectomy (Stellaris Elite\u0026trade;, Bausch\u0026thinsp;+\u0026thinsp;Lomb Corp., USA) with en-bloc removal of ERM-ILM complex. Patients with significant cataract underwent combined phacoemulsification-vitrectomy to enhance visualization of the macular region and to ensure controlled manipulation over the macula. Three standard 25 G sclerotomies were performed initially followed by core vitrectomy and induction of posterior vitreous detachment (PVD). Negative staining of ERM was done using Brilliant Blue dye to stain the ILM and areas of attached ERM appeared as no-staining areas. Removal of the ERM-ILM complex started as ILM peeled beyond the extent of ERM borders, with no direct attempts to remove the ERM. After the initial punching of the ILM, meticulously grasping the ILM toward the area of ERM was commenced to ensure complete En-bloc removal of ERM-ILM complex without shredding the ILM. After En-bloc removal of ERM-ILM complex, re-staining was performed using Brilliant Blue dye to delineate the area of the peeled complex and ensure complete removal. An additional movie file shows this in more detail [see Additional file 1].\u003c/p\u003e \u003cp\u003ePostoperative medications included topical Moxifloxacin eye drops and topical Tobramycin-Dexamethasone eye drops, and tapering of eyes drops was scheduled according to physician discern. OCT scans were repeated 3 months after surgery along with BCVA assessment.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eData were collected and analyzed with SPSS v 20.0 for windows. Numerical data were presented as means and standard deviations (SD) whereas categorical data were presented as frequencies and percentages. A p-value of less than 0.05 was used to indicate statistical significance.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eTwenty-three subjects (23 eyes), 14 males and 9 females with mean age of 61.52 \u0026plusmn; 4.6 years were recruited in the study. Baseline BCVA was 0.16 \u0026plusmn; 0.08, IOP was 15.09 \u0026plusmn; 2.36, and mean spherical equivalent was \u0026minus;2.15 \u0026plusmn; 1.73 diopters. At the time of surgery, 18 patients (80.9%) were phakic and 5 patients were pseudophakic (19.1%). In the phakic group, there was a visually significant cataract in 3 patients who planned to have combined phacoemulsification and IOL implantation with the vitrectomy surgery. Failure of En-bloc removal of ERM-ILM complex was encountered in 2 patients who were excluded from the study. Tables 1 and 2 demonstrate demographic data and baseline evaluation of the participants.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunctional visual outcome\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePostoperative mean BCVA improved significantly as compared with the baseline BCVA (0.35 \u0026plusmn; 0.16 post-operatively vs 0.16 \u0026plusmn; 0.08 at baseline, p-value: 0.005). At the 3 months postoperative visit, 18 subjects had improved in BCVA (85.7%), 2 remained stable (9.5%), and 1 patient had deteriorated of BCVA (4.8%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMacular morphological changes by OCT\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere were significant macular thickness and architectural changes after the En-bloc removal of ERM-ILM complex. Macular thickness improved from 414.76 \u0026plusmn; 63.22 \u0026micro;m at baseline to 336.95 \u0026plusmn; 43.01 \u0026micro;m at 3 months postoperatively (p-value: 0.005). Changes of foveal contour (either flat or preserved foveal depression as compared to convex configuration at baseline) after En-bloc removal of ERM-ILM complex was observed in 15 patients (15/21, 81.6%) by OCT at 3 months visit as compared with 7 patients (7/21, 33.3%) at baseline. Table 2 presents the macular morphological changes from baseline to 3 months follow-up visit. (Figures 1 and 2)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEnface OCT changes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEnface OCT revealed retinal folds in 16 patients (16/21, 80.1%) at baseline evaluation. (Table 1) Retinal folds manifested on Enface OCT as alternating white and black striation of the retinal surface related to tangential VMT exerted by the ERM. Three months postoperatively, retinal folds disappeared in 14 patients (14/16, 87.5%) and persisted in only 2 patients after En-bloc removal of ERM-ILM complex. (Figures 3 and 4) \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eVascular density and FAZ changes by OCT Angiography\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOCT angiography of SCP revealed vascular wrinkling in 19 patients (19/21, 95.5%) and vascular straightening in 17 patients (17/21, 89.5%) at baseline. Three months after surgery, vascular wrinkling and straightening improved as documented in Table 2. Furthermore, vascular density at 1 mm was improved from 17.06 \u0026plusmn; 1.59 at baseline to 24.13 \u0026plusmn; 2.40 at 3 months follow up (p-value; 0.013). On the other hand, the FAZ area at SCP decreased post-operatively from 255.57 \u0026plusmn; 44.61 \u0026micro;m\u003csup\u003e2\u003c/sup\u003e to 198.05 \u0026plusmn; 46.86 \u0026micro;m\u003csup\u003e2\u003c/sup\u003e (p-value; 0.001). Moreover, a reduction in FAZ area correlated well with improved VD (r; 0.281, p-value; 0.042). (Figures 5 and 6)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePars plana vitrectomy with ERM removal is the gold standard management of idiopathic ERM in symptomatic patients. However, the implementation of ILM peeling for ERM surgical management is debatable. Pathologically, ILM peeling will prevent the recurrence of fibroblast proliferation over the macular region as these cells are not able to proliferate in the absence of an ILM scaffold, thus theoretically preventing the recurrence of ERM formation.\u003csup\u003e10\u003c/sup\u003e \u003csup\u003e11\u003c/sup\u003e Moreover, many studies have suggested that ERM formation is associated with pathological ILM, and that the removal of this pathological ILM would reduce the incidence of ERM recurrence. \u003csup\u003e12\u003c/sup\u003e\u003csup\u003e13\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn several studies, vitrectomy for idiopathic ERM first involved ERM removal via negative staining followed by staining and peeling of ILM in 2 separate steps. \u003csup\u003e14\u003c/sup\u003e \u003csup\u003e15\u003c/sup\u003e \u003csup\u003e16\u003c/sup\u003e In the present study, we investigated the \u0026ldquo;En-bloc\u0026rdquo; removal of ERM-ILM complex to remove the ERM completely as well as the pathological ILM in a single step. En-bloc removal of ERM-ILM complex does not differ from standard steps of ILM peeling as it only starts the ILM peeling in the area beyond the borders of ERM after staining with no specific surgical learning curve.\u003c/p\u003e \u003cp\u003eIn the present study, not only the macular thickness but also the macular morphology improved after En-bloc removal of ERM-ILM complex. CMT significantly improved postoperatively from 414.76 \u0026micro;m at baseline to 336.95 \u0026micro;m after 3 months and foveal contour was restored in 81.6% of patients. Macular morphological and perfusion improvements were reflected in BCVA as BCVA significantly improved after En-bloc removal of ERM-ILM complex from 0.16 at baseline to 0.35 at 3 months (p-value: 0.005) and visual improvement was documented in 85.7% of patients.\u003c/p\u003e \u003cp\u003eSchechet et al. retrospectively evaluated patients who had vitrectomy for ERM removal with and without ILM peeling and investigated the difference in BCVA, CMT, and ERM recurrence.\u003csup\u003e17\u003c/sup\u003e They concluded that there was no significant difference in final BCVA or CMT. However, recurrence of ERM was detected in 22.9% of patients who didn\u0026rsquo;t have ILM peeling and nearly half of them needed another surgery for recurrent ERM. This study highlighted the potential benefit of ILM peeling to prevent ERM recurrence as we proposed in the current study.\u003c/p\u003e \u003cp\u003eIn contrast to the current study, Lee and Kim reported that patients who had ILM peeling exhibited higher CMT and less restoration of foveal contour (42.9%) compared to the non-peeling group (84.2%) but these differences were insignificant. \u003csup\u003e18\u003c/sup\u003e Mean reduction in CMT in ILM peeling group and the current study was similar (74.2 \u0026micro;m and 77.8 \u0026micro;m respectively). However, in the current study, 81.6% of patients had restored foveal contour compared previous study.\u003c/p\u003e \u003cp\u003eAhn et al. had a similar result when they compared patients with ERM with additional ILM peeling or not. They found that patients who had ILM peeling had worse BCVA than non-peeling at 1 month follow-up.\u003csup\u003e19\u003c/sup\u003e However, after one year follow-up, there was no significant difference between peeling and non-peeling groups regarding the final visual outcome or ERM recurrence rate.\u003c/p\u003e \u003cp\u003eA variable percentage of ERM recurrences were reported even in patients who had ILM peeling. Obata et al. reported that the recurrence of ERM over 1 year was higher and significant in the non-ILM peeling group than ILM peeling group (20.5% and 42.6% respectively). Park et al. reported that none of the patients who had ILM peeling had recurrent ERM compared to 21% of patients who didn\u0026rsquo;t have ILM peeling. \u003csup\u003e20\u003c/sup\u003e Fleissig et al. reported that the incidence rate of recurrent ERM 5 years after ERM removal without ILM peeling is approximately 58%. \u003csup\u003e21\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eSeveral studies have investigated quantitative and qualitative macular changes after ERM removal via enface OCT and OCT angiography. In the present study, enface OCT highlighted retinal folds secondary to tangential traction exerted on the macular surface by ERM in 16 patients (80.1%). After surgery, retinal folds disappeared in 14 out of 16 patients (87.5%) at 3 months follow up. This finding was also emphasized by the improvement in vascular wrinkling and straightening documented by enface OCT from 19 and 17 out of 21 patients pre-operatively to 11 and 8 out of 21 patients in 3 months follow-up visits respectively. (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Furthermore, OCT angiography revealed improved macular perfusion in terms of increased vascular density (17.06 at baseline to 24.13 at 3 months, p-value; 0.003) and reduced FAZ area (255.57 \u0026micro;m\u003csup\u003e2\u003c/sup\u003e at baseline to 198.05 \u0026micro;m\u003csup\u003e2\u003c/sup\u003e at 3 months, p-value; 0.001).\u003c/p\u003e \u003cp\u003eUlfik-Dembska et al. reported that FAZ area was negatively correlated with CMT in patients with ERM. \u003csup\u003e22\u003c/sup\u003e Mao et al. investigated the effect of ERM surgery with ILM peeling on FAZ parameters and vascular density.\u003csup\u003e23\u003c/sup\u003e In contrast to the current study, they reported that there was a minimal change in FAZ area with a reduction in foveal vascular density despite the significant improvement in final visual acuity at the final visit. Bacherini et al. highlighted OCT angiographic changes after ERM removal and ILM peeling. VD increased significantly 6 months after surgery, however, FAZ area increased 6 months after surgery, in contrast to our study. \u003csup\u003e24\u003c/sup\u003e Muller et al. reported absence of any difference in FAZ area or vascular density between ERM surgery with or without ILM peeling.\u003csup\u003e25\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eTo our knowledge, this is the first study to address the technique of En-bloc removal of ERM-ILM complex for the management of idiopathic ERM. The limitations of the present study include small number of participants and short-term follow-up. Further long-term comparative studies should be initiated to confirm the advantages of this technique.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eEn-bloc removal of ERM-ILM complex is a promising technique for the management of idiopathic ERM. Compared with non-ILM peeling techniques, it provides not only satisfactory visual gain but also macular morphological and vascular prefusion improvement with lower rates of ERM recurrence.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eConflict of interest\u003c/h2\u003e \u003cp\u003eNo conflicts of interest to disclose\u003c/p\u003e\u003ch2\u003eFunding and grants\u003c/h2\u003e \u003cp\u003eNo funding or grants were obtained\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eW.S. performed the surgery, did follow up for our patientsM.S. did OCT \u0026amp; OCTA and interpret imagesZ.E wrote the main manuscript, did statistics and discussionAll authors reviewed the manuscript\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e \u003cp\u003eNo acknowledgement to declare\u003c/p\u003e\u003ch2\u003eData availability\u003c/h2\u003e \u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e Fraser-Bell S, Guzowski M, Rochtchina E, et al. Five-year cumulative incidence and progression of epiretinal membranes: the Blue Mountains Eye Study.\u0026nbsp;Ophthalmology. 2003;110(1):34\u0026ndash;40\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Xiao W, Chen X, Yan W, et al. Prevalence and risk factors of epiretinal membranes: a systematic review and meta-analysis of population-based studies.\u0026nbsp;BMJ Open. 2017;7(9):e014644.\u0026nbsp;\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Doguizi S, Sekeroglu MA, Ozkoyuncu D, et al. Clinical significance of ectopic inner foveal layers in patients with idiopathic epiretinal membranes.\u0026nbsp;Eye (Lond). 2018;32(10):1652\u0026ndash;1660.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Gonz\u0026aacute;lez-Saldivar G, Berger A, Wong D, et al. Ectopic inner foveal layer classification scheme predicts visual outcomes after epiretinal membrane surgery. Retina. 2020 ;40(4):710\u0026ndash;717.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Mavi Yildiz A, Avci R, Yilmaz S. The predictive value of ectopic inner retinal layer staging scheme for idiopathic epiretinal membrane: surgical results at 12 months.\u0026nbsp;Eye (Lond). 2021;35(8):2164\u0026ndash;2172.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Matoba R, Morizane Y. Surgical Treatment of Epiretinal Membrane.\u0026nbsp;Acta Med Okayama. 2021;75(4):403\u0026ndash;413.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Nam SW, Byun Z, Ham DI, Kong M. Microperimetric evaluation for different methods of epiretinal membrane surgery.\u0026nbsp;BMC Ophthalmol. 2023;23(1):295.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Told R, Georgopoulos M, Reiter GS, et al. Intraretinal microvascular changes after ERM and ILM peeling using SSOCTA.\u0026nbsp;PLoS One. 2020;15(12):e0242667.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Fung AT, Galvin J, Tran T. Epiretinal membrane: A review.\u0026nbsp;Clin Exp Ophthalmol. 2021;49(3):289\u0026ndash;308.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Sivalingam A, Eagle RC Jr, Duker JS, et al. Visual prognosis correlated with the presence of internal-limiting membrane in histopathologic specimens obtained from epiretinal membrane surgery. Ophthalmology 1990;97:1549\u0026ndash;1552.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Gaudric A, Fardeau C, Goberville M, et al. Ablation of the internal limiting membrane, macular unfolding and visual outcome in surgery of idiopathic epimacular membranes. J Fr Ophtalmol 1993;16:571\u0026ndash;576\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Bovey EH, Uffer S, Achache F. Surgery for epimacular membrane: impact of retinal internal limiting membrane removal on functional outcome. Retina 2004;24:728\u0026ndash;735.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Sandali O, El Sanharawi M, Basli E, et al. Epiretinal membrane recurrence: incidence, characteristics, evolution, and preventive and risk factors. Retina 2013;33:2032\u0026ndash;2038.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Sultan H, Wykoff CC, Shah AR. Five-Year Outcomes of Surgically Treated Symptomatic Epiretinal Membranes With and Without Internal Limiting Membrane Peeling.\u0026nbsp;Ophthalmic Surg Lasers Imaging Retina. 2018;49(5):296\u0026ndash;302.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Obata S, Fujikawa M, Iwasaki K, et al. Changes in Retinal Thickness after Vitrectomy for Epiretinal Membrane with and without Internal Limiting Membrane Peeling.\u0026nbsp;Ophthalmic Res. 2017;57(2):135\u0026ndash;140.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Chang S. Controversies regarding internal limiting membrane peeling in idiopathic epiretinal membrane and macular hole. Retina 2012;32:S200\u0026ndash;S203; discussion S3\u0026ndash;S4.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Schechet SA, DeVience E, Thompson JT. The effect of internal limiting membrane peeling on idiopathic epiretinal membrane surgery, with a review of the literature.\u0026nbsp;Retina. 2017;37(5):873\u0026ndash;880.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Lee JW, Kim IT. Outcomes of idiopathic macular epiretinal membrane removal with and without internal limiting membrane peeling: a comparative study.\u0026nbsp;Jpn J Ophthalmol. 2010;54(2):129\u0026ndash;134.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Ahn SJ, Ahn J, Woo SJ, Park KH. Photoreceptor change and visual outcome after idiopathic epiretinal membrane removal with or without additional internal limiting membrane peeling.\u0026nbsp;Retina. 2014;34(1):172\u0026ndash;181.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Park DW, Dugel PU, Garda J, et al. Macular pucker removal with and without internal limiting membrane peeling: pilot study. Ophthalmology 2003;110:62\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Fleissig E, Zur D, Moisseiev E, et al. Five-year follow up after Epi-retinal membrane surgery: A Single-Center Experience.\u0026nbsp;Retina. 2018;38(7):1415\u0026ndash;1419.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Ulfik-Dembska K, Teper S, Dembski M, et al. Idiopathic Epiretinal Membrane: Microvasculature Analysis with Optical Coherence Tomography and Optical Coherence Tomography Angiography.\u0026nbsp;Tomography. 2022;8(1):189\u0026ndash;199.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Mao J, Xu Z, Lao J, et al. Assessment of macular microvasculature features before and after vitrectomy in the idiopathic macular epiretinal membrane using a grading system: An optical coherence tomography angiography study.\u0026nbsp;Acta Ophthalmol. 2021;99(7):e1168-e1175.\u0026nbsp;\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Bacherini D, Dragotto F, Caporossi T, et al. The Role of OCT Angiography in the Assessment of Epiretinal Macular Membrane.\u0026nbsp;J Ophthalmol. 2021;2021:8866407.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Muller YG, Soudier G, Olteanu S, Lenoble P. Effets du pelage de la membrane limitante interne sur la microvascularisation maculaire en OCT-angiographie dans la chirurgie des membranes \u0026eacute;pir\u0026eacute;tiniennes [Effects of internal limiting membrane peeling in epiretinal membrane surgery on OCT-angiography].\u0026nbsp;J Fr Ophtalmol. 2023;46(8):896\u0026ndash;907.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1:\u003c/strong\u003e Demographic data and ophthalmic assessment of study participants.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 72.7273%;\"\u003e\n \u003cp\u003eAge (mean \u0026plusmn; SD, years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.2727%;\"\u003e\n \u003cp\u003e61.52 \u0026plusmn; 4.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 72.7273%;\"\u003e\n \u003cp\u003eGender (M/F)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.2727%;\"\u003e\n \u003cp\u003e14/7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 72.7273%;\"\u003e\n \u003cp\u003eLens status (n, %)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Phakic\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Pseudophakic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.2727%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(17, 80.9%)\u003c/p\u003e\n \u003cp\u003e(4, 19.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 72.7273%;\"\u003e\n \u003cp\u003eMean spherical equivalent (mean \u0026plusmn; SD, diopters)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.2727%;\"\u003e\n \u003cp\u003e\u0026minus;2.15 \u0026plusmn; 1.73\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 72.7273%;\"\u003e\n \u003cp\u003ePre-BCVA (mean \u0026plusmn; SD, Decimal)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.2727%;\"\u003e\n \u003cp\u003e0.16 \u0026plusmn; 0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 72.7273%;\"\u003e\n \u003cp\u003ePost-BCVA (mean \u0026plusmn; SD, Decimal)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.2727%;\"\u003e\n \u003cp\u003e0.35 \u0026plusmn; 0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 72.7273%;\"\u003e\n \u003cp\u003eIOP (mean \u0026plusmn; SD, mmHg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.2727%;\"\u003e\n \u003cp\u003e15.09 \u0026plusmn; 2.36\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 72.7273%;\"\u003e\n \u003cp\u003eCMT at 1 mm (mean \u0026plusmn; SD, um)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.2727%;\"\u003e\n \u003cp\u003e414.76 \u0026plusmn; 63.22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 72.7273%;\"\u003e\n \u003cp\u003eEIFL (n, %)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Stage 1\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Stage 2\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Stage 3\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Stage 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.2727%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(0, 0)\u003c/p\u003e\n \u003cp\u003e(7, 33.3%)\u003c/p\u003e\n \u003cp\u003e(9, 42.9%)\u003c/p\u003e\n \u003cp\u003e(5, 23.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36.3636%;\"\u003e\n \u003cp\u003eDRIL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 36.3636%;\"\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.2727%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36.3636%;\"\u003e\n \u003cp\u003eEZ disruption\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 36.3636%;\"\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.2727%;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36.3636%;\"\u003e\n \u003cp\u003eELM disruption\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 36.3636%;\"\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.2727%;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36.3636%;\"\u003e\n \u003cp\u003eNSD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 36.3636%;\"\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.2727%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eBCVA; Best-corrected visual acuity, CMT; Central macular thickness, DRIL; Disorganized inner retinal layers, EIFL; Ectopic inner foveal layers, ELM, External limiting membrane, EZ; Ellipsoid zone, FAZ, Foveal avascular zone, IOP; Intra-ocular pressure, NSD; Neuro-sensory detachment\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2:\u003c/strong\u003e Comparison between pre- and post-operative retinal morphological and vascular perfusion changes by OCT and OCT Angiography\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"662\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 400px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRetinal architectural changes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3 months Post-operative\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOCT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155px;\"\u003e\n \u003cp\u003eFoveal contour\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003ePreserved\u003c/p\u003e\n \u003cp\u003eFlat\u003c/p\u003e\n \u003cp\u003eConvex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 155px;\"\u003e\n \u003cp\u003ePseudo-hole\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 155px;\"\u003e\n \u003cp\u003eCMT 1 mm (um)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003e414.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003e336.95\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEn-face OCT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155px;\"\u003e\n \u003cp\u003eRetinal folds\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOCT Angiography\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155px;\"\u003e\n \u003cp\u003eVascular wrinkling\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 155px;\"\u003e\n \u003cp\u003eVascular straightening\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 155px;\"\u003e\n \u003cp\u003eFAZ area (SCP)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003e255.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003e198.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 155px;\"\u003e\n \u003cp\u003eVD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003e17.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003e24.13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eCMT; Central macular thickness, FAZ, Foveal avascular, OCT; Optical Coherence Tomography, SCP; Superficial capillary plexus, VD; Vascular density.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"En-bloc, Epiretinal membrane, Internal limiting membrane peeling, Vitrectomy","lastPublishedDoi":"10.21203/rs.3.rs-6507623/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6507623/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eEn-bloc removal of ILM-ERM complex provides a radical intervention that treats not only the ERM but also the underlying diseased ILM in one step ensuring complete removal of the ERM and preventing recurrence. The aim of the study is to investigate visual and macular structural and vascular perfusion changes after En-bloc removal of ERM-ILM complex for management of idiopathic ERM.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA prospective interventional study included patients with idiopathic ERM. PPV with removal of ERM and ILM as one unit (En-bloc removal) was performed. Structural OCT was used to classify ERMs according to EIFL stage, Enface OCT was used to demonstrate ERM effect on VMI and OCT-A to highlight vascular perfusion changes at baseline and 3 months post-operatively.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eTwenty-three patients were recruited for the study, 2 patients were excluded because of failure to perform En-bloc removal of ERM-ILM complex. A significant improvement in BCVA was noted at 3 months (0.35\u0026thinsp;\u0026plusmn;\u0026thinsp;0.16, at 3 months vs 0.16\u0026thinsp;\u0026plusmn;\u0026thinsp;0.08 at baseline, p-value: 0.005). Macular thickness decreased from 414.76\u0026thinsp;\u0026plusmn;\u0026thinsp;63.22 to 336.95\u0026thinsp;\u0026plusmn;\u0026thinsp;43.01 \u0026micro;m at 3 months (p-value: 0.005). Enface OCT revealed significant retinal folds in 16 eyes at baseline that disappeared after surgery in 14 out of 16 eyes. Retinal vascular wrinkling and straightening on OCT-A were significantly ameliorated after surgery with enhancement of vascular perfusion maps (vascular density at 1 mm 17.06\u0026thinsp;\u0026plusmn;\u0026thinsp;1.59 at baseline and 24.13\u0026thinsp;\u0026plusmn;\u0026thinsp;2.40 at 3 months (p-value; 0.013).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eEn-bloc removal of ERM-ILM complex provides satisfactory visual and macular morphological improvement.\u003c/p\u003e","manuscriptTitle":"Functional and morphological outcomes of En-bloc technique for removal of ERM-ILM complex in the management of idiopathic ERM","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-07 03:28:42","doi":"10.21203/rs.3.rs-6507623/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e515a6b0-af0c-4274-9622-d01b72ab0d46","owner":[],"postedDate":"May 7th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-02T15:38:52+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-07 03:28:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6507623","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6507623","identity":"rs-6507623","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}