Anatomical and functional changes after internal limiting membrane peeling

Internal limiting membrane (ILM) peeling has been an acceptable step in vitrectomy surgeries for various retinal diseases such as macular hole, chronic macular edema following epiretinal membrane (ERM), and vitreoretinal traction. Despite all the benefits, this procedure has some side effects, which may lead to structural damage and functional vision loss. Light and dye toxicity may induce reversible and irreversible retina damage, which will be observed in postoperative optical coherence tomography scans. Retinal nerve fiber layer damage is attributed to ganglion cell degeneration and axonal transport alteration and dissociated optic nerve fiber layer is due to Müller cell damage. Eccentric MHs and recurrence of previous MHs may also lead to vision loss. Iatrogenic retinal damage may cause structural retinal changes without significant vision loss or progression to choroidal neovascularization. The mechanism of persistent macular edema after membrane peeling is still unclear, but it has been related to tractional trauma and blood-retina barrier damage. The reappearance of ERM is another cause of decreased vision after ILM peeling, which might be secondary to incomplete membrane removal. In glaucoma patients, ILM peeling is associated with significantly worsening the mean deviation on the visual field test after the surgery. We discussed various causes of vision loss and structural changes following ILM peeling. These causes may be attributed to the surgical procedure itself or the associated steps, instruments, and dyes used during the ILM peeling procedure.