Clinical and Experimental Ophthalmology 2005; 33: 576–577  Correspondence: Dr Jeffrey L Olson, 1675 Ursula, Aurora, CO 80045, USA. Email: jeffrey.olson@uchsc.edu Surgical Technique Protecting the retinal pigment epithelium during macular hole surgery Jeffrey L Olson MD, Alexander V On MD and Naresh Mandava MD Rocky Mountain Lions Eye Institute, University of Colorado, School of Medicine, Department of Ophthalmology, Aurora, Colorado, USA to apex of the perfluorocarbon liquid (PFCL) spherule. Then 0.2 mL of 0.05% ICG was injected into the fluid overlying the posterior pole, allowed to stand for 1 min, and then the fluid was aspirated with air irrigation followed by removal of the spherule of PFCL (Fig. 1). Intraoperative photos demon- strate the efficacy of this technique in preventing ICG con- tact with the macular hole (Fig. 2). Next, the internal limiting membrane was peeled under fluid and then an air– gas exchange was performed with 12% C3F8, and the patient instructed to maintain face-down positioning for 5 days. RESULTS Postoperatively, as the C 3 F 8 gas bubble absorbed, it was noted that the macular hole had closed successfully. Her vision had improved from 6/60 preoperatively to 6/18 at the 2 months visit. Postoperative fundus photographs with the ICG camera filters in place were used to demonstrate the absence of subretinal ICG in this patient (Fig. 3). ABSTRACT Herein a new surgical technique used during pars plana vit- rectomy with internal limiting membrane peeling for macular hole surgery is reported. Perfluorocarbon liquid is used to tamponade the macular hole in order to prevent indocyanine green contact with the retinal pigment epithelium. Key words: indocyanine green, internal limiting membrane peeling, macular hole, toxicity, vitrectomy. INTRODUCTION In the 12 years since Kelly and Wendel’s landmark paper 1 vitreous surgery for macular holes has experienced a contin- ual evolution of technique. A current trend is the use of indocyanine green (ICG) staining of the internal limiting membrane to facilitate the use of mechanical internal limit- ing membrane peeling. 2 However, there are indications that ICG may be toxic to the retinal pigment epithelial cells, which are exposed through a macular hole, and that subret- inal ICG may persist for up to 7 months. 3 Herein we describe a surgical technique to prevent contact between the retinal pigment epithelium (RPE) and ICG. METHODS We performed vitreous surgery on the left eye of a 70-year- old woman with a full thickness idiopathic macular hole of approximately 3 months duration. Her preoperative best- corrected visual acuity was 6/60. A standard three-port pars plana vitrectomy was performed and a posterior vitreous detachment was induced. A small spherule of perfluorocar- bon was injected nasal to the optic nerve, and then the eye rotated so that the macular hole was in the most dependent position, thus allowing the spherule of perfluorocarbon to roll gently over the retinal defect. A partial air–fluid exchange was then performed, bringing the fluid level down Figure 1. Schematic demonstrating a partial air–fluid exchange, with the spherule of perfluorocarbon liquid (PFCL) tamponading the macular hole. The indocyanine green (ICG) injected into the balanced salt solution (BSS) is contained within the posterior pole, but prevented from contact with the retinal pigment epithelium.