intravitreal, VEGF Therapy, macula

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Article Date: 9/1/2012

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UPFRONT
UPFRONT

To peel or not to peel? That is the question

Peter K. Kaiser, MD

With apologies to Shakespeare, most cooks can agree on certain situations in which you should always peel your vegetables and others in which you should never peel. With onions, garlic, and squash, one should always peel. For other vegetables, the decision to is tricky.

Is it necessary to peel potatoes before cooking? In some dishes, it makes the flavor better. In others, not so much. With cucumbers and carrots, the waxy, bitter peel makes many kids dislike these vegetables, and the loss of nutrients and fiber is minimal. In contrast, one should never peel eggplant, zucchini, or tomatoes.

The argument for and against peeling vegetables has people passionate on both sides. Besides the obvious efficiency of not having to peel your vegetables, there are health benefits to not peeling. The peels contain vitamins and nutrients and can add flavor to dishes. However, many parents argue that peeling can remove the pesticides and chemicals used in growing vegetables. Short of switching to organically grown products and scrubbing the skin before use, peeling in some situations appears logical.

We face a similar and no less contentious situation in retina when it comes to peeling the ILM. There are good arguments for and against it. In this issue, we explore the cost effectiveness and clinical utility of peeling the ILM.

Peeling ILM has been the subject of debate for many years. But to me the reason to peel ILM is simple — it's fun. Unlike peeling vegetables, I love peeling ILM. I have peeled ILM in all my macular hole, VMT, and ERM patients since I started practicing. But I also peel ILM in almost all my macular cases, including DME, PVR, and optic nerve pit cases. These cases are obviously tougher, with fraying of the ILM the norm, making the use of some sort of stain necessary to insure complete removal.

There's no time to debate the merits of staining the ILM, but one important fact recently highlighted (a recent outbreak of Fusarium endophthalmitis following the use of Brilliant Blue G compounded by a single pharmacy) was the importance of using a reputable source for your vital dyes.

Suffice it to say that when I use dyes, I use the lowest concentration possible, apply it for the shortest period of time, look for only a minimal color change, and most importantly, I keep my light pipe as far from the retinal surface as possible. This is a change from the way I was trained, when we brought the light pipe close to the macula to help us obliquely illuminate the ILM during peeling. Like anything, change is good, and moving the light away from the retina, especially in cases in which there is dye on the surface, is a wise move.

I'm sure Shakespeare never dreamed that Hamlet's speech, about whether it is better to live and bear the burdens of life or to end the pain, would ever be used to describe vegetables and the ILM, but I couldn't resist!



Retinal Physician, Volume: 9 , Issue: September 2012, page(s): 7

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