Intraoperative visualization of the internal limiting membrane (ILM), the choice of a point of vantage for lifting an initial flap, the precision with which the ILM is grasped, adhesion between the forceps and the ILM, thickness, stiffness and elasticity of the ILM as well as monitoring of the completeness of ILM removal are all important factors for safety and efficacy of a chromovitrectomy intervention. The understanding of the underlying physical features of the ILM, such as contrast behavior and bioanatomical and biomechanical properties represent, thus, useful prerequisites for successful macular surgery. New analytical tools, such as atomic force microscopy and chromaticity analysis, allow new insights into ILM material characteristics, permitting a systematic approach to refinement of surgical technique.

1.
Bottos J, Elizalde J, Arevalo JF, Rodrigues EB, Maia M: Vitreomacular traction syndrome. J Ophthalmic Vis Res 2012;7:148-161.
2.
Koerner F, Garweg J: Vitrectomy for macular pucker and vitreomacular traction syndrome. Doc Ophthalmol 1999;97:449-458.
3.
Sayegh RG, Georgopoulos M, Geitzenauer W, Simader C, Kiss C, Schmidt-Erfurth U: High-resolution optical coherence tomography after surgery for vitreomacular traction: a 2-year follow-up. Ophthalmology 2010;117:2010-2017.
4.
Schmidt-Erfurth U, Leitgeb RA, Michels S, et al: Three-dimensional ultrahigh-resolution optical coherence tomography of macular diseases. Invest Ophthalmol Vis Sci 2005;46:3393-3402.
5.
Puliafito CA, Hee MR, Lin CP, et al: Imaging of macular diseases with optical coherence tomography. Ophthalmology 1995;102:217-229.
6.
Hikichi T, Yoshida A, Trempe CL: Course of vitreomacular traction syndrome. Am J Ophthalmol 1995;119:55-61.
7.
Gregor ZJ: Surgery for idiopathic full-thickness macular holes. Eye (Lond) 1996;10:685-690.
8.
Simpson AR, Petrarca R, Jackson TL: Vitreomacular adhesion and neovascular age-related macular degeneration. Surv Ophthalmol 2012;57:498-509.
9.
Bressler NM: Age-related macular degeneration is the leading cause of blindness. JAMA 2004;291:1900-1901.
10.
Smiddy WE, Michels RG, Glaser BM, de Bustros S: Vitrectomy for macular traction caused by incomplete vitreous separation. Arch Ophthalmol 1988;106:624-628.
11.
Schwatz SD, Alexander R, Hiscott P, Gregor ZJ: Recognition of vitreoschisis in proliferative diabetic retinopathy. A useful landmark in vitrectomy for diabetic traction retinal detachment. Ophthalmology 1996;103:323-328.
12.
Gandorfer A, Rohleder M, Kampik A: Epiretinal pathology of vitreomacular traction syndrome. Br J Ophthalmol 2002;86:902-909.
13.
Gandorfer A: Objective of pharmacologic vitreolysis. Dev Ophthalmol 2009;44:1-6.
14.
Trese MT, Chandler DB, Machemer R: Macular pucker. I. Prognostic criteria. Graefes Arch Clin Exp Ophthalmol 1983;221:12-15.
15.
Kelly NE, Wendel RT: Vitreous surgery for idiopathic macular holes. Results of a pilot study. Arch Ophthalmol 1991;109:654-659.
16.
Park DW, Sipperley JO, Sneed SR, Dugel PU, Jacobsen J: Macular hole surgery with internal-limiting membrane peeling and intravitreous air. Ophthalmology 1999;106:1392-1397, discussion 1397-1398.
17.
Henrich PB, Haritoglou C, Meyer P, et al: Anatomical and functional outcome in brilliant blue G assisted chromovitrectomy. Acta Ophthalmol 2009;23:23.
18.
Haritoglou C, Ehrt O, Gass CA, Kristin N, Kampik A: Paracentral scotomata: a new finding after vitrectomy for idiopathic macular hole. Br J Ophthalmol 2001;85:231-233.
19.
Kadonosono K, Itoh N, Uchio E, Nakamura S, Ohno S: Staining of internal limiting membrane in macular hole surgery. Arch Ophthalmol 2000;118:1116-1118.
20.
Banker AS, Freeman WR, Kim JW, Munguia D, Azen SP: Vision-threatening complications of surgery for full-thickness macular holes. Vitrectomy for Macular Hole Study Group. Ophthalmology 1997;104:1442-1452, discussion 1452-1443.
21.
Burk SE, Da Mata AP, Snyder ME, Rosa RH Jr, Foster RE: Indocyanine green-assisted peeling of the retinal internal limiting membrane. Ophthalmology 2000;107:2010-2014.
22.
Maguire AM, Smiddy WE, Nanda SK, Michels RG, de la Cruz Z, Green WR: Clinicopathologic correlation of recurrent epiretinal membranes after previous surgical removal. Retina 1990;10:213-222.
23.
Livingstone BI, Bourke RD: Retrospective study of macular holes treated with pars plana vitrectomy. Aust NZ J Ophthalmol 1999;27:331-341.
24.
Lewis JM, Park I, Ohji M, Saito Y, Tano Y: Diamond-dusted silicone cannula for epiretinal membrane separation during vitreous surgery. Am J Ophthalmol 1997;124:552-554.
25.
Rodrigues EB, Meyer CH, Kroll P: Chromovitrectomy: a new field in vitreoretinal surgery. Graefes Arch Clin Exp Ophthalmol 2005;243:291-293.
26.
Haritoglou C, Gandorfer A, Gass CA, Schaumberger M, Ulbig MW, Kampik A: Indocyanine green-assisted peeling of the internal limiting membrane in macular hole surgery affects visual outcome: a clinicopathologic correlation. Am J Ophthalmol 2002;134:836-841.
27.
Iriyama A, Uchida S, Yanagi Y, et al: Effects of indocyanine green on retinal ganglion cells. Invest Ophthalmol Vis Sci 2004;45:943-947.
28.
Maia M, Kellner L, de Juan E Jr, et al: Effects of indocyanine green injection on the retinal surface and into the subretinal space in rabbits. Retina 2004;24:80-91.
29.
Sato Y, Tomita H, Sugano E, Isago H, Yoshida M, Tamai M: Evaluation of indocyanine green toxicity to rat retinas. Ophthalmologica 2006;220:153-158.
30.
Gandorfer A, Haritoglou C, Gandorfer A, Kampik A: Retinal damage from indocyanine green in experimental macular surgery. Invest Ophthalmol Vis Sci 2003;44:316-323.
31.
Ando F, Yasui O, Hirose H, Ohba N: Optic nerve atrophy after vitrectomy with indocyanine green-assisted internal limiting membrane peeling in diffuse diabetic macular edema. Adverse effect of ICG-assisted ILM peeling. Graefes Arch Clin Exp Ophthalmol 2004;242:995-999.
32.
Hisatomi T, Enaida H, Matsumoto H, et al: Staining ability and biocompatibility of brilliant blue G: preclinical study of brilliant blue G as an adjunct for capsular staining. Arch Ophthalmol 2006;124:514-519.
33.
Enaida H, Hisatomi T, Goto Y, et al: Preclinical investigation of internal limiting membrane staining and peeling using intravitreal brilliant blue G. Retina 2006;26:623-630.
34.
Enaida H, Hisatomi T, Hata Y, et al: Brilliant blue G selectively stains the internal limiting membrane/brilliant blue G-assisted membrane peeling. Retina 2006;26:631-636.
35.
Henrich PB, Priglinger SG, Haritoglou C, et al: Quantification of contrast recognizability during brilliant blue G- and indocyanine green-assisted chromovitrectomy. Invest Ophthalmol Vis Sci 2011;52:4345-4349.
36.
Macadam DL: Visual sensitivities to color differences in daylight. J Opt Soc Am 1942;32:247-273.
37.
Logvinenko AD: An object-color space. J Vis 2009;9:1-23.
38.
Kadonosono K, Arakawa A, Inoue M, et al: Internal limiting membrane contrast after staining with indocyanine green and brilliant blue G during macular surgery. Retina 2013;11:11.
39.
Meyer CH, Rodrigues EB, Kroll P: Trypan blue has a high affinity to cellular structures such as epiretinal membrane. Am J Ophthalmol 2004;137:207-208, author reply 208.
40.
Perrier M, Sebag M: Epiretinal membrane surgery assisted by trypan blue. Am J Ophthalmol 2003;135:909-911.
41.
Zhao F, Gandorfer A, Haritoglou C, et al: Epiretinal cell proliferation in macular pucker and vitreomacular traction syndrome: analysis of flat-mounted internal limiting membrane specimens. Retina 2013;33:77-88.
42.
Melles GR, de Waard PW, Pameyer JH, Houdijn Beekhuis W: Trypan blue capsule staining to visualize the capsulorhexis in cataract surgery. J Cataract Refract Surg 1999;25:7-9.
43.
Li KK, Tang EW, Li PS, Wong D: Double peel using triamcinolone acetonide and trypan blue in the management of myopic macular hole with retinal detachment: a case-control study. Clin Experiment Ophthalmol 2010;38:664-668.
44.
Li K, Wong D, Hiscott P, Stanga P, Groenewald C, McGalliard J: Trypan blue staining of internal limiting membrane and epiretinal membrane during vitrectomy: visual results and histopathological findings. Br J Ophthalmol 2003;87:216-219.
45.
Lee KL, Dean S, Guest S: A comparison of outcomes after indocyanine green and trypan blue assisted internal limiting membrane peeling during macular hole surgery. Br J Ophthalmol 2005;89:420-424.
46.
Perrier M, Sebag M: Trypan blue-assisted peeling of the internal limiting membrane during macular hole surgery. Am J Ophthalmol 2003;135:903-905.
47.
Teba FA, Mohr A, Eckardt C, et al: Trypan blue staining in vitreoretinal surgery. Ophthalmology 2003;110:2409-2412.
48.
Henrich PB, Priglinger SG, Haritoglou C, Schumann RG, Strauss RW, Schneider U, Josifova T, Cattin PC: Quantification of contrast recognizability in sequential epiretinal membrane removal and internal limiting membrane peeling in trypan blue-assisted macular surgery. Retina 2013;33:818-824.
49.
Schumann RG, Gandorfer A, Eibl KH, Henrich PB, Kampik A, Haritoglou C: Sequential epiretinal membrane removal with internal limiting membrane peeling in brilliant blue G-assisted macular surgery. Br J Ophthalmol 2010;94:1369-1372.
50.
Rodrigues EB, Meyer CH, Schmidt JC, Kroll P: Trypan blue stains the epiretinal membrane but not the internal limiting membrane. Br J Ophthalmol 2003;87:1431-1432.
51.
Farah ME, Maia M, Furlani B, et al: Current concepts of trypan blue in chromovitrectomy. Dev Ophthalmol 2008;42:91-100.
52.
Luke C, Luke M, Sickel W, Schneider T: Effects of patent blue on human retinal function. Graefes Arch Clin Exp Ophthalmol 2006;244:1188-1190.
53.
Dib E, Rodrigues EB, Maia M, et al: Vital dyes in chromovitrectomy (in Portuguese). Arq Bras Oftalmol 2009;72:845-850.
54.
Balaiya S, Brar VS, Murthy RK, Chalam KV: Comparative in vitro safety analysis of dyes for chromovitrectomy: indocyanine green, brilliant blue green, bromophenol blue, and infracyanine green. Retina 2011;31:1128-1136.
55.
Haritoglou C, Priglinger S, Liegl R, et al: Experimental evaluation of aniline and methyl blue for intraocular surgery. Retina 2009;29:1266-1273.
56.
Kushner DJ, Baker A, Dunstall TG: Pharmacological uses and perspectives of heavy water and deuterated compounds. Can J Physiol Pharmacol 1999;77:79-88.
57.
Gerding H, Timmermann M, Thelen U: Intravital staining of the internal limiting membrane with a novel heavy solution of brilliant blue G. Klin Monatsbl Augenheilkd 2011;228:298-301.
58.
Haritoglou C, Schumann RG, Kampik A, Gandorfer A: Heavy brilliant blue G for internal limiting membrane staining. Retina 2011;31:405-407.
59.
Henrich PB, Valmaggia C, Lang C, et al: Contrast recognizability during brilliant blue G- and heavier-than-water brilliant blue G-assisted chromovitrectomy: a quantitative analysis. Acta Ophthalmol 2012;20:12005.
60.
Rosenblum YZ, Zak PP, Ostrovsky MA, et al: Spectral filters in low-vision correction. Ophthalmic Physiol Opt 2000;20:335-341.
61.
Van den Biesen PR, Berenschot T, Verdaasdonk RM, van Weelden H, van Norren D: Endoillumination during vitrectomy and phototoxicity thresholds. Br J Ophthalmol 2000;84:1372-1375.
62.
Kraushar MF, Harris MJ, Morse PH: Monochromatic endoillumination for epimacular membrane surgery. Ophthalmic Surg 1989;20:508-510.
63.
Henrich PB, Valmaggia C, Lang C, Cattin PC: The price for reduced light toxicity: do endoilluminator spectral filters decrease color contrast during brilliant blue g assisted chromovitrectomy? Graefes Arch Clin Exp Ophthalmol 2013, in press.
64.
Henrich PB, Monnier CA, Monnier CA, Halfter W, Halfter W, Haritoglou C, et al: Nanoscale topographic and biomechanical studies of the human internal limiting membrane. Invest Ophthalmol Vis Sci 2012;53:2561-2570.
65.
Wollensak G, Sporl E, Pham DT: Biomechanical changes in the anterior lens capsule after trypan blue staining. J Cataract Refract Surg 2004;30:1526-1530.
66.
Balasubramani M, Schreiber EM, Candiello J, Balasubramani GK, Kurtz J, Halfter W: Molecular interactions in the retinal basement membrane system: a proteomic approach. Matrix Biol 2010;29:471-483.
67.
Erickson AC, Couchman JR: Still more complexity in mammalian basement membranes. J Histochem Cytochem 2000;48:1291-1306.
68.
Candiello J, Cole GJ, Halfter W: Age-dependent changes in the structure, composition and biophysical properties of a human basement membrane. Matrix Biol 2010;29:402-410.
69.
Halfter W, Winzen U, Bishop PN, Eller A: Regulation of eye size by the retinal basement membrane and vitreous body. Invest Ophthalmol Vis Sci 2006;47:3586-3594.
70.
Hogan MJ: The vitreous, its structure, and relation to the ciliary body and retina. Proctor Award Lecture. Invest Ophthalmol 1963;2:418-445.
71.
Fine BS: Limiting membranes of the sensory retina and pigment epithelium. An electron microscopic study. Arch Ophthalmol 1961;66:847-860.
72.
Foos RY: Vitreoretinal juncture: topographical variations. Invest Ophthalmol 1972;11:801-808.
73.
Plodinec M, Loparic M, Aebi U: Atomic force microscopy for biological imaging and mechanical testing across length scales. Cold Spring Harb Protoc 2010;2010:pdb.top86.
74.
Plodinec M, Loparic M, Aebi U: Force microscopy for biological imaging and mechanical testing across length scales; in Goldman RD, Swedlow JR (eds): Live Cell Imaging: A Laboratory Manual. Cold Spring Harbor, Cold Spring Harbor Laboratory Press, 2010.
75.
Binnig G, Quate CF, Gerber C: Atomic force microscope. Phys Rev Lett 1986;56:930-933.
76.
Last JA, Russell P, Nealey PF, Murphy CJ: The applications of atomic force microscopy to vision science. Invest Ophthalmol Vis Sci 2010;51:6083-6094.
77.
Wollensak G, Spoerl E, Wirbelauer C, Pham DT: Influence of indocyanine green staining on the biomechanical strength of porcine internal limiting membrane. Ophthalmologica 2004;218:278-282.
78.
Haritoglou C, Mauell S, Schumann RG, Henrich PB, Wolf A, Kernt M, Benoit M: Vital dyes increase lens capsule stiffness. J Cataract Refract Surg, in press.
79.
Candiello J, Cole GJ, Halfter W: Age-dependent changes in the structure, composition and biophysical properties of a human basement membrane. Matrix Biol 2010;29:402-410.
80.
Yurchenco PD, Patton BL: Developmental and pathogenic mechanisms of basement membrane assembly. Curr Pharm Des 2009;15:1277-1294.
81.
Halfter W, Monnier C, Müller D, Oertle P, Uechi G, Balasubramani M, Safi F, Lim R, Loparic M, Henrich PB: The bi-functional organization of human basement membranes. PLoS One 2013;8:e67660.
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