30/10/2026
Let's talk about Dissociated Optic Nerve Fiber Layer (DONFL) following ERM + ILM peeling.
One interesting finding that may be observed on fundus examination following vitreoretinal surgery is Dissociated Optic Nerve Fiber Layer (DONFL).
DONFL is a characteristic postoperative retinal appearance associated with internal limiting membrane (ILM) peeling, particularly during surgery for an Epiretinal Membrane (ERM) or macular hole.
🔬 WHAT EXACTLY IS DONFL?
DONFL is characterized by multiple small, arcuate, dimpling-like depressions on the inner retinal surface. These depressions typically follow the course of the retinal nerve fiber layer and may appear as a series of tiny, dark, oval or elongated spots on fundus photography.
Rather than appearing as a single lesion, they often occur in clusters, producing a distinctive pattern sometimes described as a dissociated or dimpled retinal appearance.
🔍 WHY DOES IT OCCUR?
To understand DONFL, we need to understand the surgical procedure.
An epiretinal membrane is a thin, fibrocellular membrane that develops on the inner surface of the retina, particularly around the macula. It can contract and distort the underlying retinal architecture, resulting in:
• Metamorphopsia (distorted vision).
• Blurred central vision.
• Reduced visual acuity.
• Micropsia (objects appearing smaller than they are).
Treatment may involve pars plana vitrectomy with removal of the epiretinal membrane.
Surgeons may also peel the internal limiting membrane (ILM), the thin basement membrane forming the innermost boundary of the retina, to reduce the likelihood of recurrent membrane formation.
However, ILM peeling involves manipulation of the innermost retinal surface. This manipulation may produce structural changes in the underlying retinal nerve fiber layer, contributing to the characteristic DONFL appearance.
🧠 WHAT IS THE CLINICAL SIGNIFICANCE OF DONFL?
An important point is that DONFL is generally considered a postoperative structural change rather than evidence of active retinal disease.
Although its appearance can be striking on fundus photography, its presence does not automatically indicate significant visual deterioration.
Research suggests that DONFL may be associated with subtle changes in retinal sensitivity, even when conventional visual acuity remains relatively preserved.
This highlights an important distinction: a patient may achieve good visual acuity after surgery while still demonstrating subtle structural or functional retinal changes.
🔬 HOW IS IT IDENTIFIED?
DONFL can be appreciated using different retinal imaging techniques:
1️⃣ Fundus Photography: Shows multiple characteristic dimpling-like depressions on the retinal surface.
2️⃣ Spectral-Domain OCT (SD-OCT): Helps demonstrate alterations in the inner retinal architecture and localized dimpling of the retinal surface.
3️⃣ En Face OCT: Can provide a particularly useful view of the distribution and characteristic pattern of these inner retinal changes.
4️⃣ Microperimetry: May help evaluate localized retinal sensitivity changes when functional assessment is required.
⚠️ DOES DONFL MEAN THE SURGERY WAS UNSUCCESSFUL?
Not necessarily!
DONFL can occur despite successful removal of an epiretinal membrane and improvement in macular anatomy or visual function.
It is important not to interpret every postoperative retinal surface irregularity as surgical failure or progressive retinal damage.
The clinical findings should always be correlated with the patient's symptoms, visual acuity, OCT findings and overall postoperative course.
💡 CLINICAL TAKEAWAY
DONFL is a fascinating example of how manipulation of the innermost retinal layers during vitreoretinal surgery can leave recognizable structural changes.
For optometrists, ophthalmologists and other eye-care professionals, understanding this appearance is important when interpreting postoperative fundus photographs and OCT scans.
The retina can look different after successful surgery, and not every unusual postoperative appearance represents a complication.
👁️ Look closely at the video. Can you identify the characteristic retinal dimples?
Let's discuss in the comment section!
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