\r\n\tNowadays, environmental contamination with heavy metals is one of the most severe environmental issues, which needs the synergistic action of the scientific community, the general public and diverse authorities. Unfortunately, industrial effluents containing hazardous residues are frequently discharged into the ecosystem, thus resulting in harmful effects to the environment. One of the principal sources of heavy metal pollution near rivers and estuarine streams is the intensified industrial use of metals and the process of leaching of mine tailings, hence, the drainage of untreated mines. The infiltration of heavy metals into watercourses is generally accompanied by sediment deposits that result in a high concentration of heavy metals in water, sediments and aquatic organisms. In various developing and emerging countries, studies have shown that agricultural land irrigated with wastewater contributes about 50% of plant resources to urban areas, hence, is of utmost importance for food security. Based on economic considerations, farmers are often forced to maximize production in order to generate profit, regardless of environmental concerns or human health.
\r\n\tConventional decontamination technologies used to clean up contaminated metal sites are relatively insensitive, costly and time-consuming, often dangerous for workers, and produce secondary waste, which in turn displays another environmental threat. Innovative and sustainable techniques could be promising solutions to remediation of heavy metal contamination.
Starting from the concept of configuration space (known as c-map as well), this chapter highlights the necessity of finding an alternative way to perform path search than computing the whole configuration space deterministically. Even simple 2D scenarios appears to be quite difficult to be handled by calculating the whole configuration space.
This chapter comes from the necessity of recalling the fact that such powerful and well-known algorithms like sampling based algorithms are strictly connected to the configuration space. Configuration space is the most ancient concept root of motion planning. Moreover, motion planning algorithms are generally imagined by the people as deterministic analysis of the environment because humans expect robots to be foolproof. Sampling based planners, instead, are coming from heuristic approaches which are the exact opposite of deterministic analysis. Most of the disseminating books and papers [1, 2, 3, 4, 5, 6] are focused on explaining the algorithms rather then report how and why those algorithms were born. The main contribution of this chapter is reporting how and why sampling based planners algorithms were born and which challenges older planning algorithms could not solve. Knowing the history and the ideas behind each planning algorithm allows scientists to fully understand its capabilities. Moreover, it allows scientists to know which algorithm is more eligible for a specific problem a priori without testing all of them.
Section 2 explains how to compute a full configuration space and reports several examples in order to fully address the practical meaning of c-map. Moreover, this section describes accurately which are the major drawbacks of computing the whole c-map. In many cases, computing the c-map is practically impossible.
Section 3 describes heuristic methods and their ability to tackle very convolute or large problems quickly without losing much information. Those methods do not ensure any result because they are not deterministic, but they do find a very good solution if they are well designed. This chapter is not reporting any specific heuristic method because they must be designed according to the problem.
Section 4 gives a quick overview of sampling based planners. Sampling based planes comes from the necessity of exploring configuration spaces by using heuristic methods. In particular, this section reports two of the most famous sampling based planes: Probabilistic road map (PRM) and Rapidly-exploring random tree (RRT). Those planners or a variation of them are probably the most use all around the world.
The parameters which define the configuration of a system are called generalized coordinates, and the vector space defined by these coordinates is called configuration space of the system. The configuration space represents all possible states that the system might have. According to the number of degrees of freedom of a system, its configuration space has to be defined by a vector having the same length. Due to this fact, the representation of configuration spaces on paper is limited to systems having 2 degrees of freedom.
Configuration spaces are often used in robotics to represents all possible mechanical configurations which a robot can have. Moreover, configuration spaces are used to motion planning by stacking several configurations into one motion. Given a starting configuration and a goal configuration there are infinite possible motions which lead the robot from the stating point to the goal one. Assuming that the path search is restricted to geometrical constraints (no kinematics and no dynamics is involved), the cleverest path would be defined by a straight line connecting the starting point and the goal point on the configuration space (Figure 1). However, path planning algorithms are mostly used to carry robot through obstacles. Assuming that obstacles are not moving or that they are moving slowly enough to be considered static comparted to the robot motion speed. Configuration space can be computed to describe all possible robot configurations not colliding with any obstacle. These configuration spaces are called “
C-map of a planar robot defined by 2 links and 2 rotational joints.
Creating a configuration space is simple if there are no obstacles in the scene. Knowing the range of values that each degree of freedom can have is enough to build a fully function configuration space map. Including obstacles into the scene increases significantly the complexity of building configuration space map.
Before continuing this chapter, it is better to highlight that in order to simplify the handling of the topic and help the reader to visualize all examples, all presented robots and obstacles lay into a 2D plane. Moreover, all robots are going to have just 2 degrees of freedom or less to allow 2D representation of configuration spaces.
Objects have many possible shapes in real environment, but most of them can be accurately represented by the sum of a finite number of convex shapes. For sake of simplicity, only 2D objects are taken into account in this chapter, but similar statements can be derived for 3D objects. Since 3D objects have one more dimension, the computational costs of the algorithms should generally increase by one order of magnitude. In some cases, this computational cost variation makes algorithms feasible for 2D object scenarios and not feasible for 3D object scenarios.
Robots have basically two ways to include obstacles into their path planification:
Detecting obstacles by themselves.
Having another system which constantly provides obstacles to them.
Object detection is a very broad field and many sections of it are still opened. As E. Arnold et Al reports in their paper [7], there are a lot of different techniques to detecting objects according to sensor types, sensor configurations and the operative scenarios. Due to this reason, this chapter is not going to deal with object detection. All the objects in the scene are assumed to be known and provided by another system to the path planner.
As it was mentioned before, this chapter deals with 2D objects to ensure 2D visualization. 2D objects can be convex or non-convex. As it is shown in Figure 2, convex objects do not have any internal angle larger then 180°. Non-convex objects, on the other hand, have at least one of them. Non-polygonal objects are convex by default if they are regular shapes (circles, ellipses, etc.…). If objects are defined by a concatenation of various curves, a possible solution to establish whether the object belongs to convex or non-convex shapes is rearranging the edges of the object by a set of liner segments. According to the resolution of this edge substitution, the computational cost of convex categorization changes. Higher resolution leads to high precision, but high computational cost.
Non-convex and convex 2D objects.
This convex categorization is fundamental because computing convex object collision is very easy and not computationally expensive due to computational geometry algorithms [8]. So, it is better to “convert” non-convex shapes to convex shapes. The most used techniques to perform this transformation are:
Convex hull algorithms (e.g., Graham’s scan)
Subdivision algorithm
Triangle meshing algorithm
The
Non-convex shape converted into a convex one by convex hull algorithms.
The
The
The
Non-convex shape converted into a convex one by subdivision algorithm.
The
The
Non-convex shape converted into a convex one by triangle meshing algorithm.
The major drawback of the
Since this chapter deals with known non-deformable objects, using the
According to the number of degrees of freedom of the robot, the type of degrees of freedom of the robot, the number of objects in the scene, and the shape type of those objects (circle, polygonal, etc.…), computing the “
Let us consider a trivial example: a robot defined by a single link and a single rotational joint. The rotational joint is located to one of its ends and the link can only rotate around one of it end; no translation is involved. Moreover, there just one object in the scene defined by a circle (Figure 6).
C-map of a planar robot defined by 1 link and 1 rotational joint.
Computing the c-map of this trivial example is immediate: there is just one degree of freedom represented by the angle α of the rotational joint. Since the obstacle is just one, it is sufficient to calculate for which values the link touches the obstacle without crossing its edges to know which is the valid angle range. The c-map of Figure 6 shows that the
Planar robot position for α equal to −120° and −60°.
The computational cost required to compute this c-map is almost zero.
Another trivial example is related to robots able to translate on a 2D map. In the case of a robot represented by a single point, the
C-map of a polygonal robot able to translate on a 2D map.
Let us take into account one of the most popular c-map examples: a two link planar robot having two degrees of freedom represented by the angles of the rotational joint connecting the first link to the ground and the rotational joint connecting the first link to the second one. The simplest scanario includes just one obstacle represented by a circle (Figure 9).
C-map of a planar robot defined by 2 links and 1 circular obstacle.
Due to the complexity of defining a single equation which describes accurately the
Before continuing with the chapter, is better to highlight the fact that every experiment has been performed on the same machine using a mono-thread fashion algorithm in order to avoid the possibility of using too powerful computers. Some algorithms, such as the c-map simulation search, have each iteration totally unrelated to the previous ones. This fact gives scientists the possibility to project a system which uses as many cores as the number of expected iterations to return the algorithm result immediately. Unfortunately, this approach might work in theory, but it is practically impossible for most of the cases because it would force the robot to be linked to a supercomputer which cannot be contained inside of the robot. Let us imagine that having an external facility containing this large computer would be feasible and that the algorithm should calculate the
In order to have a better understanding of the computational resources required to compute the
C-map of a planar robot defined by 2 links and 1 polygonal obstacle.
Creating the
Adding one circular object in the scene means increasing the computational cost by 1 while adding a polygonal obstacle means increasing the computational cost by 39.
In order to prove that linearly increasing the number of degrees of freedom will exponentially increase the computational cost, a bunch of experiments have been run on three link planar robot. The number of iterations required to find all possible robot configurations with a resolution of 5° is 373248. Calculating the
As soon as the c-map has been computed, another piece of the algorithm takes the lead and tries to find the path leading the robot from its initial configuration to the goal one. Sometimes, the path is a single straight line connecting the original point to the goal point on the c-map, but most of the times, the path is defined by a set of segments (Figure 11); each point connecting a segment to the following one is called way-point. Unfortunately, not all scenarios have a solution: some c-maps have more than just one obstacle free sector. If the robot is located into one of them, it cannot jump into the other one (Figure 11).
Typical 2D path solutions.
As it was mentioned in Section 2.2, the algorithm in charge of computing the c-map had to perform the colliding check of all representative configurations of the robot which means that the algorithm had create a grid of cells defined by two parameters: their position into the map (robot configuration) and a boolean value which states whether the robot collides with an obstacle or not.
Mathematically, the algorithm converts a
According to S. M. LaValle [2], the are many ways to compute a path starting from the c-map. Let us take into account, as an example, the potential field path planner. Briefly, the potential field path planner associates to each cell of the c-map to another value which comes from the sum of the attractive potential field and the repulsive potential field. The first one (a) guides the robot configuration to the goal one, while the second one (b) pushes the robot configuration far from obstacles (Figure 12).
Graphical visualization of a generic 2D potential field map having two obstacles in the scene (attractive field + repulsive filed) [
Afterward, starting from the initial configuration cell, the algorithm has to check which cell among the surrounding ones has the lower potential value and takes that as the last explored cell. Then, the algorithm has to repeat the search until the goal cell has been reached or it gets stuck into a local minima. This approach is no longer the state-of-the-art because it has many drawbacks which are not reported in this chapter. However, it has been used as an example because it is very simple and gives the perfect picture of performing a path search on a cell map.
As it was shown in Figure 11, creating the path by analyzing cell by cell might be very inefficient. Sometimes, there is even a straight line connecting the goal configuration and the initial one, but the algorithm has to waste time performing the whole c-map computation anyway. A possible strategy to overcome this issue is using a heuristic method.
Heuristic methods become very popular because they are able to find a good solution (non-optimal) in a very short time. They are specifically popular to for solving scheduling problems. Heuristic methods are not analyzing the problem step by step like most of the deterministic algorithms; they are starting directly from a potential solution. Then, they adjust this solution iteratively in order to reduce the outcome of a cost function. Heuristic algorithms look for alternative solution randomly or pseudo-randomly at every iteration until a certain time or number of iterations has been reached. In [12] a variety of heuristic methods are described. Scheduling problems find a perfect match for these algorithms because sorting randomly all items the algorithm have to schedule is already a solution. The algorithm is not supposed to create or erase some items. Path planning algorithms, instead, do have to create a set of waypoints connecting the initial configuration to the goal one on the c-map. Way-points are a set of scheduled configurations that the robot has to cross sequentially in order to reach the goal. In path planning algorithms way-points are the items to be scheduled.
Nowadays, heuristic algorithms able to create or erase items from the original schedule pool are included in the family of genetic algorithm [13, 14]. Within each generation, the number of items of the schedule is constant. From one generation to another one the number of items might change.
Coming back to the potential field planner, it practically tries to connect the initial configuration and the goal configuration by selecting the less expensive cell in term of potential field at every iteration. Each cell is a sort of waypoint that the robot has to cross. The outcome of the cost function related to potential field planners is the sum of the potential costs of all cells the algorithm plans to cross. The potential field planner deterministically finds the path by analyzing the map step by step. An alternative way to find a feasible solution is drawing a straight line connecting the goal point to initial one at first. Afterwards, if the path intersects an obstacle of the c-map, the algorithm should introduce a waypoint and making it slide on the map randomly for some iterations. If a feasible solution has not been found, the algorithm should introduce another waypoint and so on. The reader of this chapter might argue that this process might get stuck if there are no solutions because there is no way for the algorithm to understand it deterministically. (S)He would be right, but this is the drawback of using heuristic algorithms. They are very quick to find solutions if they exist, but the algorithm’s target is not finding the optimal solution. However, if the algorithm is well designed heuristic algorithms are one of the most powerful weapons to tackle path planning problems quickly.
Unfortunately, the heuristic algorithms described so far are performing the path search on the c-map. It means that the c-map has to be computed in advance anyway. Apparently, using heuristic methods speeds up the path search, but do not solve the time issue raised up by the
C-map computation progresses (20%, 50%, 80%).
The accuracy of the map is very high where the c-map has been computed, while it is null where the map has still to be processed. A feasible way to keep the accuracy homogenous over the whole map during the entire computation process is computing cells randomly on the map. Due to the “Monte Carlo’s simulation”, picking points randomly on a dataset converges quite quickly to the statistical distribution of that dataset. In this case, the dataset are the cells of the map and their statistical distribution is flat because cells are equally distant from each other.
At this point, a quite simple question might come out: “Is analyzing all cells mandatory in order to find a feasible path?”. The answer, of course, is “no”. This process of configuration space discretization is required to create a full c-map, but even rarefied c-map can lead to feasible and acceptable paths. The family of sampling based planners is the result of this idea.
Sampling based planners finds their strength into reducing dramatically the number of robot configurations taken into account during the c-map construction process. Instead of creating the full c-map, few points are randomly selected into the map in order to reduce the number of robot configuration taken into account without loosing the statistical distribution of the map. The most common algorithms belonging to this family are the probabilistic Roadmap (PRM) [3, 4] and the Rapidly-exploring Random Tree (RRT) [5, 6]. Both algorithms are throwing into the scene random points one by one and tries to connect them to the closer one in order to build a graph (PRM case) or a tree (RRT case). A connection is considered valid if the line connecting a point to another one is not crossing an obstacle. Practically, the algorithm is locally computing a c-map while it tries to connect two points. At first, it might look not so efficient because the algorithm seems to replicate the classical c-map construction with the drawback of having just a graph or a tree and not the full map. However, as soon as the number of degrees of freedom overpasses 2, the computational cost difference between building the full c-map and using a sampling based planner the significantly increases.
The first is optimal for multi agent planning algorithms because graphs do not have a starting node. The initial configuration of the robot can be located anywhere on the map and linked one node of the graph. Similarly, the goal configuration can be linked to a node of the graph. Afterwards, a graph search algorithm (Dijkstra’s algorithm [15], A* [16], etc.…) will be in charge of finding the best path on request. Exploring trees, instead, are based on node hierarchy. Every node is connected the others using a father-child fashion hierarchy. Every node must have a father except for the root node. The root node is the one corresponding to the initial robot configuration. This means that exploring the tree is extremely very fast and simply but, the algorithm has to compute the tree if the initial robot configuration changes.
Nowadays, heuristic and meta-heuristic methods are widely used because they are incredibly efficient in term of computational cost. Moreover, if they are well designed, they are able avoid local minima which are far from the global minima. Philosophically, heuristic methods are the family of problem-solving algorithms closer to human thinking. Humans uses to solve problems by attempting it practically, simulating it in their mind, or doing both at the same time. However, humans require much more time to perform this search than computers. This is one of the main reasons why drug development is so quick today. Scientists do not practically mix compounds all the time; most of their job is simulating chemical reactions.
Computing c-maps deterministically is very expensive or even impossible for a large variety of scenarios. Heuristic methods appear to be a solution because they are very quick and allows scientists to have at least a non-optimal feasible path. So, the sampling based planner family comes from the necessity of unifying c-map computation and heuristic methods into a new path planning technique.
This research has been funded by Generalitat Valenciana (PROMETEO/2020/034).
The epiretinal membrane (ERM) is a layer of fibrous, contractile tissue that develops on the interface of the vitreous and the internal limiting membrane (ILM). ERM formation is associated with increased age, diabetes, retinal vein occlusions, uveitis, and other diseases of the retina and vitreous [1]. In the majority of cases, ERMs do not significantly interfere with visual functions and may be observed [2]. However, patients who experience decreased visual acuity, metamorphopsia, or diplopia secondary to the ERM may benefit from vitrectomy with membrane peeling, which is the treatment of choice for symptomatic ERMs [2]. Postoperative complications of ERM peeling include cataract formation, retinal tears/detachments, vitreous hemorrhage, macular holes, and recurrence of ERM, therefore a thorough, individualized review of clinical and imaging prognostic factors must be performed prior to consideration for surgery [2]. Clinical factors such as age, lens status, severity, and duration of symptoms may affect postoperative visual recovery [3]. Imaging modalities, such as spectral-domain optical coherence tomography (SD-OCT), fluorescein angiography (IVFA), and fundus autofluorescence (FA) can also guide clinicians in decision-making [3]. SD-OCT characteristics, such as the thickness of the ganglion cell layer and foveola, have prognostic value in postoperative visual acuity [4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14]. OCT angiography, fluorescein angiography, fundus autofluorescence, and multifocal retinography are additional imaging modalities which have been used to predict retinal changes after ERM peeling [15, 16, 17, 18, 19, 20, 21, 22].
This chapter will review the epidemiology, classification, effect on visual function, natural disease course, and management of epiretinal membranes. Special attention will be paid to the preoperative clinical factors, imaging characteristics, and postoperative complications, most associated with epiretinal membrane peeling, that determine final visual outcome.
A Medline and Excerpta Medica database (EMBASE) search was conducted for all English language publications from 1947 to 2021 using the search term: (“ERM” OR “epiretinal membrane” OR “macular pucker“OR “pre-retinal fibrosis” OR “pre-retinal membrane” OR “cellophane maculopathy“) AND (“epidemiology” OR “classification” or “staging” OR “progression” OR “management” OR “vitrectomy” OR “peeling” OR “optical coherence tomography” OR “OCT” OR “IVFA” or “OCT-A” or “OCT angiography” OR “fluorescein angiography” OR “multifocal electroretinogram” OR “mfERG” OR “complication”). All relevant abstracts and the articles were reviewed. The search was also supplemented by manual search primarily using additional references from key articles.
An epiretinal membrane is a common condition estimated to affect approximately 7–9% of the general population [23, 24]. Certain ethnicities seem to be affected more than others; prevalence can be as high as 29% among Latinos and 39% among people of Chinese descent [25]. This condition is more common in the elderly population—one study found that 12% of people in their 70s are affected yet only 2% of people under 60 years of age are affected. Women have slightly higher rates of epiretinal membrane formation than men, and bilaterality is estimated to be 20–30% [24, 26].
An epiretinal membrane may be classified as being either idiopathic or secondary, with most cases being idiopathic [24]. Secondary causes of ERMs include retinal vein occlusions, diabetic retinopathy, uveitis, retinal tears or detachments [27]. Secondary epiretinal membranes may also be iatrogenic, triggered by both invasive (e.g., cataract, vitrectomy) and noninvasive (e.g., laser photocoagulation and cryopexy) procedures [28].
In addition to etiology, epiretinal membranes may be staged based on clinical or OCT severity. Clinically, epiretinal membranes vary from a minimal cellophane light reflex to a more opaque membrane with retinal folds [29]. The most widely used clinical classification scheme for ERMs was proposed by Gass—Grade 0: cellophane maculopathy, in which a translucent epiretinal membrane is not associated with retinal distortion; grade 1: crinkled cellophane maculopathy, in which the inner retinal surface is distorted by irregular retinal folds; grade 2: macular pucker, in which a grayish membrane causes marked retinal crinkling and macular puckering [30]. Various OCT-guided staging schemes have also been proposed based on the presence of foveal involvement, macular edema, macular holes, schisis, and the integrity of the inner foveal layers [31, 32].
Most people with epiretinal membranes have little to no visual symptoms, whereas others are more symptomatic and have progressive visual changes, including central vision loss, diplopia, metamorphopsia, and aniseikonia [2]. Metamorphopsia and diplopia can be especially debilitating, and they complicate essential daily activities such as reading and driving. Patients commonly report needing to close one eye to eliminate the distortion [2]. In addition to distortion, visual acuity is also degraded through light-filtering and scattering effects of the membrane, disruption of photoreceptor outer segments, obstruction of axoplasmic flow, tractional separation, and deformation of the outer retina [33]. Aniseikonia is caused by a traction-induced change in the distribution of photoreceptors, whereas metamorphopsia is related to tractional changes in the inner retina [33].
Anatomically, about a third of ERM cases remain stable, a third progress, and a third improve when observed for >5 years [34, 35]. Functionally, visual acuity remains stable in the majority of patients, worsens in 10% of patients, and improves in 7%, over a 2 year period [36]. Significant factors that predict progression are a lack of posterior vitreous detachment (PVD), an ERM that is attached fully (rather than focally) to the retina, and an early stage of ERM [33, 36]. In cases that do progress, ERM contraction causes retinal thickening, disappearance of the fovea pit, and disruption on the ellipsoid zone [33]. The timescale for progression is slow, spanning several years [33].
The majority of patients with ERMs do not require treatment and may be observed due to minimal symptoms at baseline and slow rate of progression [2, 34, 36]. For symptomatic patients, the mainstay of treatment is surgical requiring a pars plana vitrectomy with epiretinal membrane peeling [2]. In general, visual outcome after ERM peeling is favorable. Patients who elect to undergo vitrectomy with ERM peeling experience an average improvement in visual acuity of two or more lines and improvement in vision-related quality of life [2, 37]. Additionally, 70% of patients experience an improvement in metamorphopsia after ERM peeling, with 20% reporting a complete resolution of visual distortion [37].
Treatment with enzymatic or pneumatic vitreolysis may be used for isolated vitreomacular traction; however, these therapies have not been found to improve functional outcomes in patients with concurrent ERM [2]. Ocriplasmin, a recombinant proteolytic enzyme, has been found to release vitreomacular traction (VMT) in 8.7% of patients who have VMT in addition to an ERM (compared to 1.5% with placebo injection) without improvement in visual acuity [38]. C3F8 gas injection has been shown to release VMT in 50–83% of patients with concurrent ERMs, but also without improvement in visual acuity [39, 40].
Despite overall favorable outcomes, 10–20% of patients will have unchanged or worse vision following surgery; therefore, a review of each patient’s prognostic factors is advised prior to considering surgical intervention [2].
Both severity and duration of visual symptoms may be useful factors in predicting postoperative visual acuity. In a systematic review of prognostic factors for ERM peeling, Miguel and Legris discovered a heterogeneity regarding baseline visual acuity as a prognostic factor, finding that a low baseline VA appeared to be a poor prognostic factor in the majority of studies [3, 41]. Low baseline VA was also correlated with ERM recurrence [3, 42]. Duration of ERM-induced visual symptoms is inversely correlated to postoperative VA improvement—patients with symptoms of less than 1 year have the greatest improvement in VA [43, 44].
Age also impacts VA improvement after ERM surgery. Patients younger than 75 years old have a higher chance (42% in one study) of achieving postoperative BCVA of 20/20, compared with the patients who are older than 75 years of age [43]. However, older age should not be a deterrent for undergoing ERM peeling, since 66% of patients older than 75 years of age gained more than two Snellen lines in visual acuity postoperatively [43, 45]. In another study, which evaluated prognostic factors based on ERM etiology, younger patients with the secondary ERM as a result of previous retinal detachment surgery were found to have more significant visual improvement than the older patients [44].
Patients with preoperative pseudophakia were found to have better improvement in postoperative VA compared with phakic patients [41]. Cataract formation is the most common complication of PPV with ERM peeling (47–89% develop cataracts), so this finding may be at least partially due to phakic patients developing cataracts postoperatively [46, 47].
Spectral-domain optical coherence tomography (SD-OCT) captures the reflection of a broad-bandwidth light source to provide a high-definition image of the retinal layers [48]. Anatomical retinal changes after ERM peeling have been studied extensively by spectral-domain optical coherence tomography (SD-OCT).
The ganglion cell complex (GCC) consists of the three innermost retinal layers: the nerve fiber layer, the ganglion cell layer, and the inner plexiform layer. ERM peeling is associated with thinning of the GCC, most prominently in the temporal region [4, 5, 6]. A greater GCC reduction was found to be correlated with worse postoperative VA in some studies [4, 7] and improved postoperative VA in another study [8]. Postsurgical GCC thinning is correlated with retinal displacement of the fovea toward the optic disc [6].
The thickness of the foveola also carries a prognostic value. Eyes with the highest postoperative reduction in central foveal thickness were found to have the best improvement in VA and more significant reduction of metamorphopsia [9, 10]. In a comparison between each retinal layer thickness and its ratio of the central foveal thickness, a higher central foveal thickness/GCC ratio postoperatively was shown to be the most significant factor that is associated with the improved VA [11].
The rods and cones make up one of the outermost layers of the retina, known as the photoreceptor layer. Baseline integrity of the inner/outer segment junction (IS/OS) of the photoreceptor layer is associated with improved postoperative visual acuity and reduction in metamorphopsia. [10, 12, 13]. Similarly, postoperative incidence of an intact IS/OS junction is correlated with a higher VA improvement [14]. The gradual improvement in the IS/OS junction postsurgically most likely results from the slow functional recovery of the photoreceptors, leading to the VA improvement. The best improvement in VA after the ERM surgery usually occurs approximately 1 year after the surgery [14, 49].
Cystoid macular edema (CME) has the potential to affect all retinal layers—it can induce thinning of the GCC, cause disruption of the IS/OS junction, increase in the central foveal thickness, and lead to the development of cystic spaces primarily in the outer nuclear layer (ONL) [12, 50, 51, 52]. CME is a poor prognostic factor for VA improvement both when it is present at baseline and when it occurs postsurgically [12, 51].
Microcystic macular edema (MME), a distinct process from CME, is characterized by the absence of fluorescein leakage on FA [53]. Unlike CME, MME does not change foveal thickness and consists of more uniform, ellipsoidal cystic spaces localized to the inner nuclear layer (INL) [54]. MME typically occurs postsurgically after ERM peeling, possibly as a result of the damage to Müller cells and subsequent changes in the osmotic gradient, however, it does not seem to have an impact on visual recovery [50, 53, 54].
Lipofuscin is the by-product of the metabolism of photoreceptor external segments. Its density and distribution in the retinal pigment epithelium (RPE) can be demonstrated by fundus autofluorescence (FA) imaging [15]. Patients with normal autofluorescence were found to have the best postoperative improvement in visual acuity when compared with patients with hypoautofluorescent patterns [16]. Baseline hypoautofluorescence is associated with IS/OS segment disruption, while hyperautofluorescence is correlated with a greater reduction in postoperative central foveal thickness without affecting postoperative VA [16, 17].
OCT-A is a noninvasive technology which utilizes laser reflectance of the surface of moving red blood cells to depict vessels of the retina and choroid [18]. No differences in the superficial vascular plexus were found on OCT-A, when compared before and after the ERM surgery by Romano et al. [19]; however, a postoperative decrease in vessel density was demonstrated by Mastropasqua et al. [20]. The deep perifoveal capillary-free zone was found to increase postsurgically in patients with diabetic ERM, unlike with idiopathic ERM. Both those changes do not seem to affect postoperative VA recovery [19].
Unlike the OCT-A, fluorescein angiography (IVFA) maps out chorioretinal vasculature using the fluorescence of an intravenous dye. Patients with RPE abnormalities, demonstrated on preoperative FA, had a higher central foveal thickness preoperatively, a higher macular volume preoperatively, a more extensive ERM, and a greater BCVA improvement postoperatively [17]. This may be explained by the fact that the macular traction (with resultant macular thickness and RPE abnormalities) seems to be a reversible cause of visual loss, or by the ceiling effect, related to the data showing that patients with better preoperative BCVA have lower rates of improvement [17].
The multifocal electroretinogram (mfERG) is a noninvasive, objective measure of retinal electrical activity in response to a light stimulus. It is used for detection of localized abnormalities within the macula. It was found that mean, P1, and N1 mfERG amplitude were decreased in the eyes with ERMs preoperatively, but no significant change was noted after ERM peeling [21, 22]. There was also no correlation found between the multifocal ERG values and the central foveal thickness and visual acuity [21].
Cataract formation is the most common complication after ERM peeling—de Bustros et al. found that 47% of patients developed nuclear sclerosis within 3 years, and Reilly et al. found that 89% of patients developed nuclear sclerosis within 1 year [46, 47]. There was no change in the incidence of anterior subcapsular cataracts, and only 4% of patients developed posterior subcapsular cataracts [46].
Recurrence of ERM is another possible complication of ERM peeling. About 4–5% of all patients undergoing ERM peeling develop a recurrence within 1 year of surgery, while half of them would require a reoperation due to visually significant symptoms [42, 47].
Some surgeons choose to peel the underlying internal limiting membrane, while peeling an ERM. Although visual outcomes and anatomical retinal changes of ERM peeling with or without ILM removal seem to be equivalent, a lower ERM recurrence, a lower reoperation rate, but a higher rate of macula hole development were observed in patients who undergo ILM peeling in addition to ERM removal [55, 56]. Sandali et al. compared the two methods and found that only 2.6% of patients in the group of both ERM and ILM removal developed an ERM recurrence within 1 year, and 8.6% of ERM recurrence was noted in a group of patients who underwent only ERM peeling without ILM peeling [42]. A proposed explanation for this observation is that ILM peeling removes the scaffold for myofibroblast proliferation, and this can contribute to the recurrence of ERM [57].
Of patients who underwent ERM removal with ILM peeling, 1.7% were found to have macular holes postoperatively, while very few cases of macular hole development were noted in patients with ERM removal without ILM peeling [56]. The majority of macular holes were outside the fovea and appeared to be non-visually significant [56].
Retinal breaks and detachments are uncommon while utilizing current vitrectomy surgical methods [2]. Retinal detachments occur in 1% of cases during PPV with ERM peeling performed using a 23-gauge cannula system and in 3.5% of cases undergoing 20-gauge vitrectomy [2, 58, 59]. The incidence of retinal breaks ranges from 1 to 6% in the literature [60, 61].
Epiretinal membranes are a common finding, especially in the geriatric population. The majority of patients with ERMs do not require any treatment, but those who develop symptoms such as blurred vision or metamorphopsia may benefit from vitrectomy with ERM peeling. Vitrectomy with membrane peeling, although effective in relieving symptoms in most cases, has complications such as cataract formation, retinal breaks/detachments, ERM recurrence, and macular holes. Complications can be minimized and good outcomes maximized, through the careful consideration of prognostic factors in selecting surgical candidates. Clinical characteristics correlated with better postoperative VA include younger age, baseline pseudophakia, and shorter duration of symptoms. Physicians should also consider performing imaging tests such as OCT, IVFA, and autofluorescence (FA) to assist with decision-making. Patients who have a baseline integrity of the IS/OS junction on OCT, lack of cystic macular edema, normal autofluorescence on FA, and presence of RPE abnormalities on IVFA tend to have better postoperative visual outcomes and therefore may be good surgical candidates. With appropriate optimization and patient selection, epiretinal membrane peeling represents the best therapeutic intervention for this disabling disease. As trials continue to move forward, there remains the promise of continued improvements in technique and technologies, which will one day serve as a cure.
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\n\nAll translated Chapters have to be properly attributed in accordance with the requirements included in IntechOpen's Attribution Policy. Besides proper attribution translated sections of Works must include the following sentence: "This is an unofficial translation of a work published by IntechOpen. The publisher has not endorsed this translation".
\n\nAll rights to Books and other compilations are reserved by IntechOpen. The copyright to Books and other compilations is subject to a Copyright separate from any that exists in the included Works.
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In cases, the ultrasound appearance is a cystic image with different content and the differential diagnosis is often difficult. Body—research methods: the organs affected by abdominal congenital anomalies involve the gastrointestinal tract (stomach, duodenum, small bowel or colon, and gall bladder), the kidney and urinary tract, the peritoneal cavity (ascites), suprarenal glands, and tumors of the reproductive system (especially the ovaries). In order to identify the affected structures, it is mandatory to know the normal aspect of the abdominal content at different gestational ages. The diagnosis may be very difficult, but its accuracy is important, considering the need of further counseling the couple. In minor conditions, without chromosomal anomalies or associations, the outcome is usually good, and there are even possibilities of in utero treatment. In severe conditions, with poor outcome, the couple can choose to terminate the pregnancy, after counseling is provided. Conclusion: abdominal congenital anomalies are common findings in ultrasound screenings for anomalies in all the trimesters of pregnancy and their recognition is important for subsequent management.",book:{id:"6307",slug:"congenital-anomalies-from-the-embryo-to-the-neonate",title:"Congenital Anomalies",fullTitle:"Congenital Anomalies - From the Embryo to the Neonate"},signatures:"Ples Liana and Anca Lesnic",authors:[{id:"212333",title:"Associate Prof.",name:"Liana",middleName:null,surname:"Ples",slug:"liana-ples",fullName:"Liana Ples"}]},{id:"64417",title:"Introductory Chapter: A Comprehensive Approach to the Process of Breastfeeding",slug:"introductory-chapter-a-comprehensive-approach-to-the-process-of-breastfeeding",totalDownloads:1267,totalCrossrefCites:0,totalDimensionsCites:0,abstract:null,book:{id:"6191",slug:"selected-topics-in-breastfeeding",title:"Selected Topics in Breastfeeding",fullTitle:"Selected Topics in Breastfeeding"},signatures:"René Mauricio Barría P",authors:[{id:"88861",title:"Dr.",name:"R. Mauricio",middleName:null,surname:"Barría",slug:"r.-mauricio-barria",fullName:"R. Mauricio Barría"}]},{id:"62854",title:"The Surgical Technique of Caesarean Section: What is Evidence Based?",slug:"the-surgical-technique-of-caesarean-section-what-is-evidence-based-",totalDownloads:2448,totalCrossrefCites:1,totalDimensionsCites:1,abstract:"Caesarean section is the most frequent obstetric operation which is associated with increased maternal morbidity and mortality. Although these risks are low, affected women may suffer from severe consequences and this may affect subsequent pregnancies and deliveries. A variety of surgical approaches have been described, however, on low evidence level. The objective of this chapter is therefore to systematically search the literature and analyse the available evidence including preoperative workup, prophylactic antibiotics, skin disinfection, preoperative bladder catheterization as well as details of the individual steps of the actual operation itself such as skin incision types, preparation of soft tissue and womb, removal of the placenta, cervical dilatation and stitching of the womb, peritoneum, rectus muscle, fascia, subcutaneous fat, and skin. We systematically searched for meta-analysis, systematic reviews, and big studies and evaluated the evidence for each individual step.",book:{id:"6707",slug:"caesarean-section",title:"Caesarean Section",fullTitle:"Caesarean Section"},signatures:"Jan-Simon Lanowski and Constantin S. von Kaisenberg",authors:[{id:"100660",title:"Prof.",name:"Constantin",middleName:"Sylvius",surname:"Von Kaisenberg",slug:"constantin-von-kaisenberg",fullName:"Constantin Von Kaisenberg"},{id:"240353",title:"Dr.",name:"Jan-Simon",middleName:null,surname:"Lanowski",slug:"jan-simon-lanowski",fullName:"Jan-Simon Lanowski"}]},{id:"18348",title:"Anaesthetic Considerations during Laparoscopic Surgery",slug:"anaesthetic-considerations-during-laparoscopic-surgery",totalDownloads:28882,totalCrossrefCites:1,totalDimensionsCites:5,abstract:null,book:{id:"916",slug:"advanced-gynecologic-endoscopy",title:"Advanced Gynecologic Endoscopy",fullTitle:"Advanced Gynecologic Endoscopy"},signatures:"Maria F. Martín-Cancho, Diego Celdrán, Juan R. Lima, Maria S. Carrasco-Jimenez, Francisco M. Sánchez-Margallo and Jesús Usón-Gargallo",authors:[{id:"14715",title:"Prof.",name:"Francisco M.",middleName:null,surname:"Sánchez-Margallo",slug:"francisco-m.-sanchez-margallo",fullName:"Francisco M. Sánchez-Margallo"},{id:"29449",title:"Dr.",name:"Maria Fernanda",middleName:null,surname:"Martín-Cancho",slug:"maria-fernanda-martin-cancho",fullName:"Maria Fernanda Martín-Cancho"},{id:"39772",title:"Dr.",name:"Juan R.",middleName:null,surname:"Lima",slug:"juan-r.-lima",fullName:"Juan R. Lima"},{id:"39773",title:"Mr.",name:"Diego",middleName:null,surname:"Celdran",slug:"diego-celdran",fullName:"Diego Celdran"},{id:"39774",title:"Prof.",name:"Jesus",middleName:null,surname:"Usón-Gargallo",slug:"jesus-uson-gargallo",fullName:"Jesus Usón-Gargallo"},{id:"62320",title:"Prof.",name:"Maria Sol",middleName:null,surname:"Carrasco-Jiménez",slug:"maria-sol-carrasco-jimenez",fullName:"Maria Sol Carrasco-Jiménez"}]},{id:"41721",title:"Artificial Insemination in Poultry",slug:"artificial-insemination-in-poultry",totalDownloads:9531,totalCrossrefCites:5,totalDimensionsCites:14,abstract:null,book:{id:"3206",slug:"success-in-artificial-insemination-quality-of-semen-and-diagnostics-employed",title:"Success in Artificial Insemination",fullTitle:"Success in Artificial Insemination - Quality of Semen and Diagnostics Employed"},signatures:"M.R. Bakst and J.S. Dymond",authors:[{id:"155683",title:"Dr.",name:"Murray R.",middleName:null,surname:"Bakst",slug:"murray-r.-bakst",fullName:"Murray R. Bakst"},{id:"167852",title:"Dr.",name:"Jessica",middleName:null,surname:"Dymond",slug:"jessica-dymond",fullName:"Jessica Dymond"}]}],onlineFirstChaptersFilter:{topicId:"189",limit:6,offset:0},onlineFirstChaptersCollection:[{id:"80860",title:"From Open to Minimally Invasive: The Sacrocolpopexy",slug:"from-open-to-minimally-invasive-the-sacrocolpopexy",totalDownloads:35,totalDimensionsCites:0,doi:"10.5772/intechopen.101308",abstract:"With an increased demand for pelvic organ prolapse surgeries as the population ages, mesh-related osteomyelitis will become more prevalent. This case series enriches the paucity of data on management options for delayed osteomyelitis related to pelvic organ prolapse mesh. A literature review revealed no case reports of delayed onset osteomyelitis presenting up to a decade after colpopexy mesh placement. We present three cases of delayed osteomyelitis, their presentation, diagnosis and management at a tertiary academic referral center. Patients presented between 1 and 10 years after mesh colpopexy. Three different mesh materials were utilized during the initial procedures: Restorelle Y, Gynamesh and Gore-Tex mesh. The first case demonstrates failed expectant management with eventual surgical intervention on a medically compromised patient. The two subsequent cases describe elective complete mesh resection after several prior failed mesh revision attempts. This short case series and literature review illustrates that mesh-related osteomyelitis after a remote sacrocolpopexy carries significant morbidity. Mesh removal by means of minimally invasive surgery in the hands of an experienced surgical team utilizing DaVinci Robotic System is a good option and may lead to best patient outcomes.",book:{id:"11040",title:"Hysterectomy - Past, Present and Future",coverURL:"https://cdn.intechopen.com/books/images_new/11040.jpg"},signatures:"Adriana Fulginiti, Frank Borao, Martin Michalewski and Robert A. Graebe"},{id:"80782",title:"Cases of Postpartum Hemorrhage and Hysterectomy in Thailand’s Northern and Northeastern Provincial Hospitals",slug:"cases-of-postpartum-hemorrhage-and-hysterectomy-in-thailand-s-northern-and-northeastern-provincial-h",totalDownloads:31,totalDimensionsCites:0,doi:"10.5772/intechopen.102948",abstract:"PPH is a major cause of maternal death. Hysterectomy is safe to treat uncontrollable PPH. However, it may not be the best option for women who want to have children. The risk score tool to detect PPH earlier is needed in low-resource cities such as Chiang Rai and Sakon Nakhon province. This study aims to perform a risk score tool to prevent PPH in the northern and northeastern hospitals in Thailand; using mixed methods, identify risk factors for PPH from 20 articles globally and in Thailand using Med Calc, and develop the tool for prediction of PPH; and tool testing and a one-year follow-up on PPH-related hysterectomy cases. Results showed that this risk score tool can detect PPH earlier, reducing the number of PPH and hysterectomy cases. This risk score tool needs to be implemented in the same situations as hospitals to save pregnant women’s lives.",book:{id:"11040",title:"Hysterectomy - Past, Present and Future",coverURL:"https://cdn.intechopen.com/books/images_new/11040.jpg"},signatures:"Thawalsak Ratanasiri, Natakorn I. Tuporn, Somnuk Apiwantanagul, Thitima Nutrawong, Thawalrat Ratanasiri and Amornrat Ratanasiri"},{id:"80633",title:"Hysterectomy: Past, Present and Future",slug:"hysterectomy-past-present-and-future",totalDownloads:27,totalDimensionsCites:0,doi:"10.5772/intechopen.103086",abstract:"Hysterectomy is a major operation and is as old as time. This chapter touches briefly on the history of this procedure, its present aspects and general advice for these women who may need a hysterectomy, and finally the direction of new developments about it.",book:{id:"11040",title:"Hysterectomy - Past, Present and Future",coverURL:"https://cdn.intechopen.com/books/images_new/11040.jpg"},signatures:"Zouhair Odeh Amarin"},{id:"80589",title:"Total Vaginal Hysterectomy for Unprolapsed Uterus",slug:"total-vaginal-hysterectomy-for-unprolapsed-uterus",totalDownloads:54,totalDimensionsCites:0,doi:"10.5772/intechopen.101383",abstract:"Vaginal hysterectomy was the first method to extract the uterus. Vaginal hysterectomy goes back a long way into the history of medicine. Although the first hysterectomy was carried out by Themison of Athens in the year 20 B.C., the idea of extracting the uterus through the vagina was first mentioned in 120 B.C. by Soranus of Ephesos, a distinguished obstetrician. The first elective vaginal hysterectomy was performed by J. Conrad Langenbeck in 1813. The patient was a 50-year-old multipara, who suffered from chronic pelvic pain attributed to a prolapsed uterus with a hard, bleeding tumor. The operation was carried out in challenging conditions, without anesthesia, proper instruments, or surgical assistants. Until the early 1950s, vaginal hysterectomy was the method of choice for removing the uterus. With the widespread introduction of general anesthesia and antibiotic therapy, the site of vaginal hysterectomy was taken over by abdominal hysterectomy. With the introduction of minimally invasive surgery in gynecology, vaginal hysterectomy has regained its place. Harry Reich performed the first total laparoscopic hysterectomy in 1989, being one of the most renowned vaginal surgeons, and he still claims at the beginning of the 21st century that … when the first choice of approach for hysterectomy is possible, is the vaginal route. This chapter presents the relevant anatomy from the point of view of the vaginal surgeon and the standard technique used by the author in over 5,000 vaginal hysterectomies. All intraoperative drawings and photographs are original.",book:{id:"11040",title:"Hysterectomy - Past, Present and Future",coverURL:"https://cdn.intechopen.com/books/images_new/11040.jpg"},signatures:"Petre Bratila"},{id:"80400",title:"Laparoscopic Hysterectomy in Morbidly Obese Patients",slug:"laparoscopic-hysterectomy-in-morbidly-obese-patients",totalDownloads:33,totalDimensionsCites:0,doi:"10.5772/intechopen.101307",abstract:"The following chapter will focus on laparoscopic hysterectomy in morbidly obese patients. The discussion reviews the physiological changes associated with morbid obesity and the potential implications on pneumoperitoneum during laparoscopic surgery. Important considerations such as perioperative care and operating room setup are discussed. Additionally, obtaining abdominal access, reviewing the surgical approach, and post-operative considerations are all highlighted within this chapter.",book:{id:"11040",title:"Hysterectomy - Past, Present and Future",coverURL:"https://cdn.intechopen.com/books/images_new/11040.jpg"},signatures:"Merima Ruhotina, Annemieke Wilcox, Shabnam Kashani and Masoud Azodi"},{id:"80238",title:"Surgical Site Infection after Hysterectomy",slug:"surgical-site-infection-after-hysterectomy",totalDownloads:59,totalDimensionsCites:0,doi:"10.5772/intechopen.101492",abstract:"Surgical site infections (SSIs) are associated with increased morbidity, mortality, and healthcare costs. SSIs are defined as an infection that occurs after surgery in the part of the body where the surgery took place. Approximately 1–4% of hysterectomies are complicated by SSIs, with higher rates reported for abdominal hysterectomy. Over the past decade, there has been an increasing number of minimally invasive hysterectomies, in conjunction with a decrease in abdominal hysterectomies. The reasons behind this trend are multifactorial but are mainly rooted in the well-documented advantages of minimally invasive surgery. Multiple studies have demonstrated a marked decrease in morbidity and mortality with minimally invasive surgeries. Specifically, evidence supports lower rates of SSIs after laparoscopic hysterectomy when compared to abdominal hysterectomy. In fact, the American College of Obstetricians and Gynecologist recommends minimally invasive approaches to hysterectomy whenever feasible. This chapter will review the current literature on surgical site infection (SSI) after hysterectomy for benign indications.",book:{id:"11040",title:"Hysterectomy - Past, Present and Future",coverURL:"https://cdn.intechopen.com/books/images_new/11040.jpg"},signatures:"Catherine W. Chan and Michael L. 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",coverUrl:"https://cdn.intechopen.com/series/covers/22.jpg",latestPublicationDate:"May 18th, 2022",hasOnlineFirst:!0,numberOfPublishedBooks:1,editor:{id:"356540",title:"Prof.",name:"Taufiq",middleName:null,surname:"Choudhry",slug:"taufiq-choudhry",fullName:"Taufiq Choudhry",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000036X2hvQAC/Profile_Picture_2022-03-14T08:58:03.jpg",biography:"Prof. Choudhry holds a BSc degree in Economics from the University of Iowa, as well as a Masters and Ph.D. in Applied Economics from Clemson University, USA. In January 2006, he became a Professor of Finance at the University of Southampton Business School. He was previously a Professor of Finance at the University of Bradford Management School. He has over 80 articles published in international finance and economics journals. 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