LHEP in Retinitis Pigmentosa: Negative Stain, ICG Peel & Macular Hole Closure

A rare case of Retinitis Pigmentosa with LHEP and a degenerative lamellar macular hole. Watch how negative staining with ICG guides a precise LHEP peel and leads to successful macular hole closure.

An RP Story with an Unexpected Guest
Some eyes carry stories long before they carry symptoms.
This 46 year old man had lived with Retinitis Pigmentosa since his teens —
a slow dimming of the world,
a night sky that arrived too early,
a tunnel that kept narrowing.

But three months ago, the left eye dimmed faster.
Too fast.
Fast enough to make him pause.

On the fundus, the familiar constellation of RP greeted us —
bone spicule shadows, attenuated vessels,
a pale disc that had watched decades of quiet degeneration.

Yet the OCT told a newer tale.

In the right eye, foveal schisis and a lamellar macular hole.
In the left, a degenerative LMH waiting for attention.
And in both eyes, that unmistakable signature —
a double layer sign,
where a thick, homogeneous veil of LHEP
sat apart from the ILM like a second skin.
A Müller cell whisper,
a sign of degeneration rather than traction.

His vision had slipped to 6/60,
and we offered him a chance —
a guarded one —
through pars plana vitrectomy.

In surgery, Brilliant Blue refused to speak.
So we turned to ICG,
and the dye revealed its secret in reverse —
a negative stain,
a dark island marking the LHEP.

That was our doorway.
We lifted the membrane gently,
circumferentially,
respecting its nature —
gelatinous, tenacious, unlike any ERM.
Once freed, it was trimmed,
and the fovea finally breathed again.

A week later, the OCT smiled back.
The macular hole had closed,
and his vision rose to 6/24 —
not perfect,
but brighter than before.

Because sometimes, even in RP,
the retina still has room
for small victories.

A 46 year old man presented with rapidly progressive visual decline over the past three months. He was a known case of Retinitis Pigmentosa, diagnosed in his teenage years, with long standing reduced vision. However, he noted a further drop in vision in the left eye during the recent three month period.
Fundus examination in both eyes showed the classical stigmata of RP.
OCT imaging revealed:
• Right eye: Foveal schisis with an associated lamellar macular hole
• Left eye: A lamellar macular hole
In both eyes, OCT demonstrated a distinct, homogeneous epiretinal proliferation clearly separated from the internal limiting membrane, creating a double layer configuration at the vitreoretinal interface. This appearance is characteristic of degenerative lamellar macular holes, consistent with lamellar hole–associated epiretinal proliferation (LHEP).
His best corrected visual acuity in the left eye had declined to 6/60, and he was advised pars plana vitrectomy for the lamellar macular hole, with a guarded visual prognosis given the underlying Retinitis Pigmentosa and degenerative foveal changes.
He underwent a three port pars plana vitrectomy without peripheral vitreous base shaving. Brilliant Blue G did not provide adequate staining of the epiretinal tissue; therefore, ICG dye was used. A negative stain clearly delineated the area of lamellar hole–associated epiretinal proliferation (LHEP).
Peeling was initiated at the margin of the negative stain, and the epimacular proliferation was gently elevated and removed in a circumferential fashion. As expected, LHEP appeared thick, gelatinous, and tenacious, distinctly different from the typical contractile epiretinal membrane. After completing the peel, the residual LHEP was carefully trimmed using the vitrectomy cutter.
A fluid–air exchange was performed.
At one week postoperative follow up, the lamellar macular hole was closed, and the best corrected visual acuity improved to 6/24.
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Видео LHEP in Retinitis Pigmentosa: Negative Stain, ICG Peel & Macular Hole Closure канала Retinal Surgery Simplified