Preoperative Classification of Submembrane Spaces for Optical Coherence Tomography

Abstract

Purpose: To evaluate optical coherence tomography (OCT)-guided epiretinal membrane (ERM) surgery using the preoperative retinal evaluation system for surgery classification in a retrospective, comparative case series. Methods: In a masked study, 137 eyes undergoing ERM surgery with this OCT-guided system were compared with 71 consecutive controls undergoing conventional surgery. Using spectral-domain OCT, ERMs were preoperatively classified into 4 categories based on submembrane space characteristics, allowing for a tailored surgical approach. Main outcomes included first-attempt success, surgical complications, and 3-month visual acuity. Results: Compared with controls, patients receiving our OCT-guided approach had significantly higher first-attempt success (89.2% vs 57.2%; P < .001) and lower rates of petechial hemorrhage (40.0% vs 85.0%; P < .001) and macular breaks (0% vs 8.0%; P < .001). First-attempt success varied by class (P < .01), and mean operative time was reduced by 28% (19.6 vs 25.1 min; P < .001). Visual improvement was significantly greater in the guided group at 3 months (+16.2 vs +11.2 ETDRS letters; P < .01). Conclusions: The preoperative retinal evaluation system for surgery classification provides a practical framework for surgical planning in ERM cases. This OCT-guided approach helps stratify surgical risk, identify optimal engagement points, increase efficiency, and guide technique selection. Preoperative OCT-guided planning offers significant advantages over conventional methods, resulting in improved success rates and reduced complications.

Keywords

optical coherence tomography OCT epiretinal membrane ERM membrane peeling vitrectomy retina

Introduction

Epiretinal membranes (ERMs) are fibrocellular proliferations growing on the surface of the retina.^1–5 While some ERMs are idiopathic and linked to posterior vitreous detachment, others are associated with retinal breaks, retinal detachment, macular holes, uveitis, and retinal vascular disease such as diabetes and hypertension.⁶ Within the macula, these membranes may contain a variety of cells, including myofibroblasts, retinal pigment epithelial cells, fibrous astrocytes, and macrophages.⁷

ERMs display contractile properties that transmit tangential forces to the retina, with subsequent distortion.^7,8 They can also induce retinovascular changes, leading to retinal edema, ischemia, and microdetachment.^9–11 There is evidence that prolonged traction may lead to irreversible vision loss owing to structural damage to photoreceptors.^11,12 Patient symptoms of decreased vision and metamorphopsia are a frequent indication for surgery, which presents technical challenges due to the delicate nature of the required macular manipulation.

Vitrectomy and membrane peeling are procedures that have demonstrated positive functional and visual outcomes.^13–15 The extremely close surgical maneuvers on the macular surface, however, are demanding. Limited stereopsis, reduced depth of field, transparent tissue planes, and variable membrane-retina adhesion make it difficult to identify an ideal location to start peeling the membrane. The use of surface contrast can indicate the presence of an elevated membrane edge, but this could also represent an area of firm adhesion to an underlying convoluted or edematous retina. The application of intravitreal dyes (brilliant blue G or indocyanine green) or triamcinolone particles may provide some clues.^16,17 Since most surgeries are performed under local anesthesia, patient movement adds to the challenge.

Several surgical instruments have been developed to create the initial plane for separating the superficial membrane from the retina. These include the needle, microvitreoretinal blade, blunt pick, extrusion needle, Tano diamond-dusted scraper, flex-loop, and end-grasping forceps.^1,9,17–20 Once a surgical plane between the membrane and retina is created, forceps are often used to peel the membrane tangentially off the surface of the retina. Alternatively, forceps can be used to “pinch” the membrane without first creating a surgical plane, but this technique frequently requires multiple attempts. During a pinch-and-peel maneuver, intraoperative complications such as iatrogenic retinal breaks or crush injuries can happen in the macula and are more likely to occur in areas where the membrane is firmly adhered to the retina. Intraoperative petechiae indicate retinal capillary hemorrhage and violation of the internal limiting membrane (ILM).

While vitrectomy with membrane peeling is generally successful and has good functional outcomes, the very close surgical maneuvers on the macular surface are technically demanding. Using optical coherence tomography (OCT), artificial intelligence models can diagnose and predict outcomes in patients with ERMs.^21–24 Intraoperative OCT has improved ERM peeling by providing real-time visualization of the membrane during surgery, which can enhance surgical decision-making.^25–28 However, preoperative OCT analyses to plan ERM surgical approaches have not been systematically compared with conventional surgical approaches.

The premise of this study was based on the correlation of preoperative OCT imaging features with intraoperative surgical observations. We previously used preoperative OCT to identify optically empty submembrane spaces as ideal locations to initiate pinch-and-peel ERM removal, since submembrane spaces represent a preexisting surgical plane between the ERM and underlying retina.²⁹ Simultaneous en face imaging allowed surgeons to overlay 2-dimensional OCT vertical scans onto 2-dimensional fundus images. This preoperative membrane map guided membrane peeling in the operating room.

Our experience indicated that pinching the ERM with forceps at a mapped submembrane space location was far more likely to generate a surgical plane and lead to efficient ERM removal, with fewer complications. At the same time, membrane maps also revealed areas of tight ERM-retina adherence to be avoided. Interestingly, the location of the submembrane space could not be predicted by reviewing fundus photography or by location during surgery, when surgeons instead focus their attention on areas of transparency loss or contrast changes. This suggests that the appearance of the anterior surface of ERM provides little indication of its surgically important posterior surface features. To further evaluate these findings, this study describes the establishment of an ERM surgical classification system using this preoperative approach in a comparative study.

Methods

Study Design and Population

A retrospective review of a consecutive, comparative interventional case series was conducted at Erie Retina Research (Erie, PA). The study included 208 eyes undergoing primary ERM surgery, with 137 eyes using the preoperative retinal evaluation system for surgery OCT-guided approach, and 71 consecutive control eyes using a conventional surgical technique on a 2:1 ratio. The same surgical team operated on both groups during the same period. The study was approved by the institutional review board and conducted in accordance with the principles outlined in the Declaration of Helsinki. Written informed consent was obtained from all participants.

Classification and Control Group

For the OCT-guided group, ERMs were categorized based on specific OCT characteristics, using both clinical examination and spectral-domain OCT imaging (Table 1). Two independent observers performed the classification. The control group underwent standard preoperative assessment without specific OCT-guided classification or surgical planning. Methods for OCT imaging and analysis, data collection, statistical analysis, quality control and standardization, surgical standardization, and scanning electron microscopy are described in the Supplemental Methods. The primary endpoint of first-attempt success was defined as achieving at least a one-fourths-disc-diameter area of ERM elevation with the initial pinch-and-peel maneuver. This was determined by a post-hoc review of surgical video recordings by an independent grader masked to the preoperative plan (OCT-guided vs conventional).

Table 1.

Classification System for Epiretinal Membrane Types.

ERM Type	Description	Fundus Photography	OCT Features	Surgical Approach	Special Considerations
1	Elevated ERMs with a broad, deep submembrane space	Variable appearance of opaque and transparent areas	Displays a clear, broad, and deep separation between the ERM and the retina with optically empty submembrane spaces	End-grasping forceps are typically sufficient	Key identifiers: edge visibility and elevation pattern
2	ERMs with focal, shallow submembrane space (not extremely taut)	Variable appearance of opaque and transparent areas	Shows a more uniform membrane with focal, shallow submembrane space	Staining with trypan blue, brilliant blue, or Kenalog	A membrane scraper, flex loop, retinal pick, or bent microvitreoretinal blade may be used to create an edge
3	Very thick and taut ERMs without submembrane space or optically opaque submembrane space	May show a shiny, reflective surface	A flat, smooth membrane closely opposed to the retina without submembrane space or with optical opacities between the ERM and retina	May require staining and sharp dissection with a pick, membrane scraper, or flex loop	Delicate handling is essential due to tight adherence
4	ERMs with VMT	May show macular distortion or elevation due to traction	Reveals vitreous pulling on the macula, often with retinal elevation	VMT can assist in peeling the ERM	After ERM removal, vital staining facilitates ILM peeling

Abbreviations: ERM, epiretinal membrane; ILM, internal limiting membrane; OCT, optical coherence tomography; VMT, vitreomacular traction.

Classification for ERM Surgery

The preoperative retinal evaluation system for surgery (PRESS) is a classification method that uses OCT to categorize ERMs based on the characteristics of the submembrane space (Figure 2). This preoperative analysis helps guide the surgical approach by identifying optimal points to begin membrane peeling, stratifying risk, and increasing efficiency.

ERM Types

Type 1

Type 1 is characterized by a broad, deep, and optically empty submembrane space, indicating a clear separation between the membrane and the retina (Figure 2, A–E). These membranes are often elevated, and the surgical approach typically only requires the use of end-grasping forceps. They have the highest first-attempt grasp success rate at 95.3%.

Type 2

Type 2 indicates a focal, shallow, and optically empty submembrane space (Figure 2, F–J). These membranes have a more uniform appearance with limited areas of separation. Surgery may require staining with brilliant blue G or triamcinolone to better visualize the membrane before attempting to create an edge for peeling.

Type 3

Type 3 membranes are thick and taut, displaying either no submembrane space or an optically opaque submembrane space (Figure 2, K–O), suggesting multiple points of firm attachment to the retina. This type is the most challenging, often requiring sharp dissection with a pick or flex loop to create an initial surgical plane. It has the lowest first-attempt success rate in the study, at 71.4%.

Type 4

Type 4 is defined by the presence of vitreomacular traction, where the vitreous is still attached and pulling on the macula (Figure 2, P–T). The associated ERM can have various submembrane space patterns. Surgically, the vitreous traction itself can be leveraged to help separate the membrane from the retina during the vitrectomy.

Surgical Technique

The same standardized surgical setup was used for both groups, including anesthesia, preparation, and port placement. In the OCT-guided group, membrane removal was guided by preoperative OCT-identified optimal grasp points in a preidentified submembrane space. In the control group, conventional membrane engagement was performed without the use of specific OCT guidance. The ILM was not routinely removed or stained. All other aspects of the procedure remained identical between groups, including core vitrectomy, staining techniques when needed, and wound closure.

A retrobulbar or subconjunctival anesthetic block was administered. Following sterile preparation and draping, a lid speculum was inserted. Three 25-gauge valved trocar/cannula systems (Alcon) were placed using a standardized approach. The inferotemporal cannula was positioned 3.5 mm posterior to the limbus using a beveled technique to create a 3-plane, self-sealing incision.³⁰ Similar cannulas were placed in the superotemporal and superonasal quadrants. The position and function of the infusion cannula were confirmed before activation. Visualization was achieved using the BIOM (Oculus Surgical) or Zeiss Resight widefield viewing system (Carl Zeiss).

Initial vitrectomy involved careful assessment of posterior vitreous detachment status. In cases without pre-existing posterior vitreous detachment, the vitreous was separated from the retina using aspiration with the vitreous cutter. A core vitrectomy was then performed, systematically removing all unopacified vitreous. A diluted 50% mixture of triamcinolone acetonide was used to enhance visualization of any residual vitreous and to confirm posterior vitreous detachment and the absence of traction or breaks along the vitreous base using scleral depression.

Preoperative classification and an image of the membrane map with OCT-identified optimal grasp points were brought to the operating room and used to guide the surgical initiation site for a pinch-and-peel membrane removal. A macular contact lens provided enhanced visualization. Alcon disposable ILM or membrane forceps were used to perform pinch and peel maneuvers. In the OCT-guided group, initial membrane engagement was attempted at a preidentified submembrane space where there was an existing surgical plane with a significant separation between the membrane and underlying retina (Figure 1). The technique was modified according to our classification.

For type 1 membranes, direct engagement with ILM forceps was used. Type 2 membranes required staining with brilliant blue G (0.025%) or triamcinolone steroid (Kenalog) to facilitate membrane surface visualization before pinch-and-peel maneuvers. Type 3 membranes necessitated careful dissection to create an initial surgical plane by using a flex loop, pick, or membrane scraper as previously described.³¹ Type 4 cases incorporated vitreomacular traction–guided approaches in which, during the core vitrectomy and creation of a posterior vitreous detachment, anterior-posterior vitreous traction also helped to separate the ERM from the retina. Achieving at least a one-fourths-disc diameter area of ERM separation after the first pinch and elevation was scored as successful.

Cost-Utility Analysis

Following the methodology of Gupta et al,¹³ we performed a cost-utility analysis from a societal perspective. Costs were estimated based on Medicare reimbursement rates for vitrectomy, anesthesia, and facility fees. Quality-adjusted life-years were calculated based on the visual acuity gains in each group, using previously published utility values for different states of vision. The primary outcome was the cost per quality-adjusted life-year gained.

Statistical Analysis

Post hoc analysis of the 208 eyes demonstrated sufficient statistical power (>80%) to detect clinically meaningful differences in our primary endpoints: first-attempt success rate (20% difference), operative time (15% reduction), and complication rate (15% reduction). Between-group comparisons were performed using the Student t test for continuous variables and χ² or Fisher exact test for categorical variables. P < .05 was considered statistically significant. Mean values are ± SD.

Results

Demographics and Baseline Characteristics

A total of 208 eyes (137 OCT-guided, 71 conventional) were included in the study. Baseline characteristics were similar between groups (Table 2). The mean age was 65 years in both groups, and there was a comparable gender distribution (51% female in the OCT-guided group, 52% female in the control group) and similar rates of pseudophakia (67% vs 65%). Forty percent of cases in both groups were idiopathic. Preoperative visual acuity and central macular thickness were also comparable between groups.

Table 2.

Patient Demographics and Clinical Characteristics.

Characteristic	OCT-Guided (n=137)	Conventional (n=71)	P Value
Age (y)			.92
Mean	65	65
Range	12-92	14-90
Sex, n (%)			.97
Male	66 (48.2)	34 (47.9)
Female	71 (51.8)	37 (52.1)
Lens status, n (%)			.73
Phakic	45 (32.8)	25 (35.2)
Pseudophakic	92 (67.2)	46 (64.8)
Etiology, n (%)
Idiopathic	55 (40.1)	28 (39.4)	.83
Diabetic retinopathy	21 (15.3)	27 (38.0)	.91
Uveitis	17 (12.4)	9 (12.6)	.88
Other (macular hole, retinal detachment, age-related macular degeneration, vitreomacular traction)	17 (12.4)	7 (0.01)	.86

Abbreviation: OCT, optical coherence tomography.

Classification and Surgical Outcomes

In the OCT-guided group, ERMs were classified preoperatively as type 1, with broad, deep, optically empty submembrane spaces (43 eyes, 31.4%); type 2 showed focal submembrane space (62 eyes, 45.2%); type 3 displayed more closely opposed and shallow areas of separation with optically opaque submembrane space and opacities connecting the posterior surface of the membrane to the retina (21 eyes, 15.3%); and type 4 had vitreomacular adhesions and various submembrane space configurations (11 eyes, 8.1%) (Table 1). Submembrane spaces were mapped onto fundus images to guide surgeons to the location of the optimal site to initiate an ERM pinch-and-peel maneuver.

In both groups, surgical objectives were achieved in all cases, but with significant differences in efficiency and complications (Table 3). The first-attempt success rate for achieving at least a one-fourths-disc area of ERM separation was significantly higher in the OCT-guided group compared with the conventional approach (89.2% vs 57.2%, P < .001). The OCT-guided group required fewer attempts (mean, 1.0 vs 1.32 attempts; P < .001) and demonstrated shorter operative times (mean, 19.6 vs 25.1 minutes; P < .001). Within the OCT-guided group, first-attempt success varied by classification: type 1, 95.3%; type 2, 82.1%; type 3, 71.4%; and type 4, 81.8%. Even the lowest success rate, in type 3 cases (71.4%), exceeded that of the conventional approach (57.2%, P < .01).

Table 3.

ERM Classification and Surgical Characteristics.

ERM Type	Number (%) of Patients	First-Attempt Success (%)	Petechial Rate (%)	Operative Time (Min)
1	43 (31.4)	95.3	23.3	12.3
2	62 (45.2)	82.1	47.9	18.7
3	21 (15.3)	71.4	52.4	25.4
4	11 (8.1)	81.8	45.5	22.1
Control group	71 (100)	57.2	85.0	25.1

Abbreviation: ERM, epiretinal membrane.

While type 1 and 2 membranes showed optically empty submembrane space, type 3 membranes displayed submembrane space opacities, suggesting a mechanical attachment between the ERM and retina. They were the most adherent areas during surgical peeling. A type 3 membrane was analyzed via scanning electron microscopy (Figure 3). On the anterior surface, there were cellular elements and vitreous collagen filaments (72 nm ± 15 nm). The posterior surface showed fine filaments corresponding to elastin at the ILM-ERM interface, with distinctive curvilinear stringlike elements averaging 30 nm ±6 nm in diameter, significantly thinner than vitreous collagen. These fibrils exhibited properties that were consistent with elastin, including characteristic branching patterns with resistance to mechanical stress that we previously identified in macular hole ERMs.¹

The elastin fibers formed interconnected networks between the ERM and ILM surfaces, suggesting a role as contractile elements. In areas where the ERM was partially elevated, these elastin fibers can anchor the ERM undersurface to the ILM, maintaining a mechanical connection between the membrane and retina.¹ Further scanning electron microscopy of different membrane types could confirm correlative OCT findings.^32,33

Complications

The OCT-guided approach demonstrated significantly lower complication rates compared with conventional surgery, including petechial hemorrhages (40.0% vs 85.0%, P < .001) and retinal breaks (0% vs 8.0%, P < .001) (Table 4). In the OCT-guided group, petechial hemorrhages showed significant variation by type, occurring in 23.3% of type 1 cases vs 47.9% of type 2 cases (P < .01) (Table 3).

Table 4.

Comparative Surgical and Visual Outcomes.

Outcome Measure	OCT-Guided (n=137)	Conventional (n=71)	P Value
Surgical parameters
First-attempt success (%)	89.2	57.2	<.001
Mean attempts needed (n)	1.0	1.32	<.001
Mean operative time (min)	19.6 min	25.1 min	<.001
Complications
Petechial hemorrhages (%)	40.0	85.0	<.001
Macular breaks (%)	0.0	8.0	<.001
Visual outcomes
Visual acuity improvement (number of letters)	16.2	11.2	<.01
Final visual acuity (logMAR) ± SD	0.30 ± 0.20	0.40 ± 0.22	<.01
Cost per quality-adjusted life-year ($)	4,680	5,980	<.01

Abbreviation: OCT, optical coherence tomography.

Visual and Anatomical Outcomes

Both groups had improved visual acuity, but the OCT-guided group demonstrated superior outcomes (Table 4). Mean logMAR visual acuity improved from 0.70 ± 0.25 (approximately 20/100 Snellen) preoperatively to 0.30 ± 0.20 (approximately 20/40 Snellen) at 3 months in the OCT-guided group, compared with a mean logMAR improvement from 0.71 ± 0.26 to 0.40 ± 0.22 in the control group. The difference in visual improvement was significant, with the OCT-guided group gaining 5 ETDRS letters (+16.2 vs +11.2 letters, P < .01). Mean central macular thickness decreased from 410 ± 85 μm preoperatively to 295 ± 45 μm at 3 months postoperatively in the OCT-guided group, with similar anatomical improvement in the control group (405 ± 88 μm to 301 ± 48 μm).

Subgroup Analysis

Idiopathic ERM cases in both groups showed better outcomes than secondary cases. In the OCT-guided group, idiopathic cases (n=55) showed a mean visual improvement of 3.2 lines with 89.1% first-attempt success, compared with secondary cases (n=82) with 2.8 lines of improvement and 82.9% first-attempt success (P = .04 for visual acuity difference). Similar trends were observed in the control group, but with lower overall success rates.

Cost-Utility Analysis

Subgroup analysis revealed significant differences based on membrane etiology. Idiopathic cases (n=55) showed better outcomes, with a mean visual acuity improvement of 3.2 lines and a first-attempt success rate of 89.1%. Secondary cases (n=82) demonstrated less improvement, with 2.8 lines of visual gain and an 82.9% first-attempt success rate (P = .04 for visual acuity difference). Lens status had a minimal impact on outcomes, with pseudophakic patients (n=92) gaining 3.1 lines and phakic patients (n=45) gaining 2.9 lines (P = .45).

Following the methodology of Gupta et al,¹³ overall cost-utility analyses demonstrated favorable economics, with a quality-adjusted life-year gain of 0.755 and a cost per quality-adjusted life-year of $4,680 (sensitivity analysis range, $3,746-$6,245). Moreover, favorable economics were demonstrated in both groups, with improved efficiency in the OCT-guided group vs the control group (mean cost per quality-adjusted life-year, $4,680 vs $5,890, respectively; P < .01).

Conclusions

Our study demonstrates that compared with conventional approaches, preoperative OCT-guided analysis to classify submembrane spaces can significantly improve surgical outcomes and efficiency in ERM peeling. Clinical examination and review of fundus images alone do not enable clear identification of optimal and safe locations for ERM peeling.

In conventional surgery, surgeons are often drawn to areas of the retina with higher contrast, which presumably suggest a thickened membrane, edge, or underlying tissue variation amenable to grasping with forceps. However, these high-contrast sites could also represent areas of firm adhesion between the ERM and the retina. Our comparative data show that the OCT-guided approach results in significantly higher first-attempt success rates (71.4%-95.3% vs 57.2%, P < .001), validating the utility of this classification system. Our finding builds upon the work of Snead et al,⁸ which demonstrated the importance of membrane separation patterns in surgical outcomes.

OCT morphological insights correlated strongly with surgical difficulty across both patient groups. The higher rate of petechial hemorrhages in conventional surgery (85.0% vs 40.0%, P < .001) supports the idea that unguided membrane engagement often occurs at points of tight adherence. Even within the OCT-guided group, type 2 cases showed higher hemorrhage rates than type 1 cases (47.9% vs 23.3%, P < .01), supporting the value of preoperative imaging in risk stratification.

The complete absence of retinal breaks in our OCT-guided group represents an unexpected improvement over our control group results, as well as findings from previous reports. Using conventional techniques, Kadonosono et al¹⁴ reported a 1% to 3% rate of retinal breaks, while Gandorfer et al noted microscopic retinal damage in up to 5% of cases. The improved safety profile may be attributed to the OCT-guided, precise identification of optimal grasp points.

Visual outcomes were superior with OCT-guided surgery, demonstrating an additional 5-letter improvement compared with the conventional approach. The visual improvement in our OCT-guided series (mean number of lines, 3.2 in idiopathic cases) compares favorably with previous reports. Tognetto et al¹⁷ demonstrated a mean visual improvement of 2.5 lines using conventional techniques, while Kadonosono et al¹⁴ reported a 2.8-line visual improvement at 6 months. The better outcomes in our series likely reflect reduced surgical trauma due to precise grasp point selection.

There are significant limitations of this study. While consecutive case selection helps minimize bias, this was not a randomized trial; however, the use of the same surgical teams during the same period strengthens the comparisons. Most of the cases were type 1 and type 2, which might emphasize those outcomes compared with type 3 and 4 ERMs. Surgeon experience with OCT-guided planning could also influence outcomes, though the improved efficiency and reduced complications suggest real benefits beyond a learning curve effect.

The control group was smaller than the OCT-guided group but was still adequately powered to detect meaningful differences. Although the randomization should create an unbiased submembrane space distribution, the control group did not undergo post hoc submembrane space analysis and had more diabetic retinopathy–associated ERMs.

The current study focused on anatomic features of the posterior ERM rather than the anterior surface. It is possible that anterior ERM elevations and edges could also play a role in surgical planning and maneuvers. ERMs were qualitatively assessed and could favor OCT readers and surgeons familiar with this approach. An automated, quantitative approach to preoperative OCT analysis and membrane mapping could address many of these issues by systematically measuring ERM features.^29,34–36

Lastly, expanding the approach to include more surgeons at various sites in a randomized controlled trial would better establish the generalizability and value of preoperative OCT submembrane space analysis in surgical outcomes. A key limitation of this study is its single-center design, which might limit the generalizability of our findings to other patient populations and settings. Furthermore, the procedures were performed by experienced surgeons familiar with the OCT-guided technique. A learning curve might exist, and outcomes in less specialized centers, or with surgeons new to the method, may differ. A future multicenter randomized trial would be necessary to validate these findings and assess generalizability.

Image-guided surgical planning is common across surgery, but such an approach is not systematically utilized in ERM peeling. The high-resolution images available with OCT, which allow for the visualization of the posterior surface of the membrane and its relationship to the retina, provide vitreoretinal surgeons with an opportunity for more precise preoperative planning that can drive efficiency, increase safety, and improve outcomes.

In conclusion, OCT-guided ERM peeling represents a systematic approach to improving surgical technique in membrane removal. The method seems to reduce complications while maintaining high success rates. Further studies with larger cohorts and longer follow-up will help validate the preoperative retinal evaluation system for surgery classification method.

Supplemental Material

sj-docx-1-vrd-10.1177_24741264261428309 – Supplemental material for Preoperative Classification of Submembrane Spaces for Optical Coherence Tomography–Guided Epiretinal Membranectomy

Supplemental material, sj-docx-1-vrd-10.1177_24741264261428309 for Preoperative Classification of Submembrane Spaces for Optical Coherence Tomography–Guided Epiretinal Membranectomy by David R.P. Almeida, Eric K. Chin and Vinit B. Mahajan in Journal of VitreoRetinal Diseases

Supplemental Material

sj-docx-2-vrd-10.1177_24741264261428309 – Supplemental material for Preoperative Classification of Submembrane Spaces for Optical Coherence Tomography–Guided Epiretinal Membranectomy

Supplemental material, sj-docx-2-vrd-10.1177_24741264261428309 for Preoperative Classification of Submembrane Spaces for Optical Coherence Tomography–Guided Epiretinal Membranectomy by David R.P. Almeida, Eric K. Chin and Vinit B. Mahajan in Journal of VitreoRetinal Diseases

Footnotes

Acknowledgements

We thank Alton Szeto for help with graphical illustrations, MaryAnn Mahajan for editorial assistance, and Theodore Leng for sharing clinical images.

Ethical Approval

The study was approved by the institutional review board and conducted in accordance with the principles outlined in the Declaration of Helsinki.

Statement of Informed Consent

Written informed consent was obtained from all participants.

Declaration of Conflicting Interests

The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr. Almeida and Dr. Mahajan have a pending patent application related to the methods presented and an equity interest in SurgMAPai. The authors declare no other potential conflicts of interest with respect to the research, authorship, and/or publication of the article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

David R.P. Almeida

Vinit B. Mahajan

Supplemental Material

Supplemental material is available online with this article.

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