Visual improvement and regeneration of retinal layers in eyes with small, medium, and large idiopathic full-thickness macular holes treated with the inverted internal limiting membrane flap technique over a period of 12 months

Comparison of the use of internal limiting membrane flaps versus conventional ILM peeling on post-operative anatomical and visual outcomes in large macular holes

BACKGROUND

Idiopathic full-thickness macular hole (iFTMH) closure rates following conventional vitrectomy, gas tamponade and internal limiting membrane (ILM) peeling decrease when the minimum linear diameter (MLD) ≥ 500 microns. ILM flap creation has been proposed to improve closure in larger holes. This study evaluated the anatomical and functional impact of ILM flap introduction to routine practice in iFTMH ≥500 microns.

METHODS

Retrospective, interventional analysis of prospectively collected data of 191 eyes from consecutive surgeries for primary iFTMH ≥500 microns performed by two surgeons between June 2018 and June 2022, during which both surgeons replaced ILM peeling with ILM flap creation. Post-operative best-corrected visual acuity (BCVA) and anatomical closure were compared between Group 1 (ILM peel) and Group 2 (ILM flap) in an intention-to-treat analysis.

RESULTS

Rates of iFTMH closure were greater in the ILM flap group (77/80; 96.3%) than the ILM peel group (94/110; 85.5%) (OR = 4.37, 95% CI = 1.23-15.55, p = 0.023). A non-significant increase in post-operative BCVA improvement was observed in the ILM flap group (p = 0.084). There was no statistically significant difference in final BCVA (p = 0.83). Multivariate logistic regression found only MLD (OR = 0.993, 95% CI = 0.989-0.997, p = 0.001) and ILM flap group (OR = 5.795, 95% CI = 1.313-25.570, p = 0.020) predicted primary closure.

CONCLUSION

ILM flap creation improves closure rates in larger holes and should be considered routinely in iFTMH ≥500 microns. Whether ILM flaps affect post-operative visual function remains uncertain.

Minimal Posterior Pole Vitrectomy and Fixing the Inverted Internal Limiting Membrane Flap with DisCoVisc for Macular Hole: No Gas or Air Tamponade

PURPOSE

To investigate an alternative surgical method for macular hole repair without fluid-air exchange, gas tamponade, and prone positioning.

METHODS

Eighteen eyes of 17 patients with macular holes underwent minimal posterior pole vitrectomy with an inverted internal limiting membrane flap technique. Ophthalmic viscosurgical device was used to fix the inverted internal limiting membrane flap in the balanced salt solution. No fluid-air exchange, gas tamponade, or prone positioning was needed. Follow-ups were performed at 1 day, 1 week, and the last visit (ranging from 3 to 6 months) after surgery. Optical coherence tomography examination, intraocular pressure, and best-corrected visual acuity measurements were performed preoperatively and at every follow-up, postoperatively.

RESULTS

Primary closure of the macular hole was observed in all 18 eyes (100%). Optical coherence tomography showed U-type closure in 12 eyes, V-type closure in five eyes, and W-type closure in one eye. Preoperative, postoperative 1 week, and last follow-up best-corrected visual acuity were 0.90 (Snellen equivalent 20/159) ± 0.31 LogMAR, 0.72 (Snellen equivalent 20/105) ± 0.33 LogMAR, and 0.48 (Snellen equivalent 20/60) ± 0.32 LogMAR, respectively. Postoperative visual acuity was significantly improved compared with preoperative values ( F = 19.250, P = 0.000). No significant difference in intraocular pressure was found compared with preoperative values ( F = 1.933, P = 0.168). No significant complications were observed.

CONCLUSION

This surgical method can effectively close macular holes, improve visual acuity, enhance surgical efficiency, reduce surgical complications, and improve patients' postoperative experience without the need for fluid-air exchange, gas tamponade, or prone positioning.

The Short-Term Results of Autologous Platelet-Rich Plasma as an Adjuvant to Re-Intervention in the Treatment of Refractory Full-Thickness Macular Holes

The purpose of this study was to investigate the short-term efficacy and safety of autologous platelet-rich plasma (a-PRP) as an adjuvant to revisional vitrectomy for refractory full-thickness macular holes (rFTMHs). We conducted a prospective, non-randomized interventional study including patients with rFTMH after a pars plana vitrectomy (PPV) with internal limiting membrane peeling and gas tamponade. We included 28 eyes from 27 patients with rFTMHs: 12 rFTMHs in highly myopic eyes (axial length greater than 26.5 mm or a refractive error greater than -6D or both); 12 large rFTMHs (minimum hole width > 400 μm); and 4 rFTMHs secondary to the optic disc pit. All patients underwent 25-G PPV with a-PRP, a median time of 3.5 ± 1.8 months after the primary repair. At the six-month follow-up, the overall rFTMH closure rate was 92.9%, distributed as follows: 11 out of 12 eyes (91.7%) in the highly myopic group, 11 out of 12 eyes (91.7%) in the large rFTMH group, and 4 out of 4 eyes (100%) in the optic disc pit group. Median best-corrected visual acuity significantly improved in all groups, in particular from 1.00 (interquartile range: 0.85 to 1.30) to 0.70 (0.40 to 0.85) LogMAR in the highly myopic group (p = 0.016), from 0.90 (0.70 to 1.49) to 0.40 (0.35 to 0.70) LogMAR in the large rFTMH group (p = 0.005), and from 0.90 (0.75 to 1.00) to 0.50 (0.28 to 0.65) LogMAR in the optic disc pit group. No intraoperative or postoperative complications were reported. In conclusion, a-PRP can be an effective adjuvant to PPV in the management of rFTMHs.

Glial-Plug Proliferation after Inverted Internal Limiting Membrane Flap Technique for Idiopathic Macular Hole

Purpose

This study aimed to analyze the effect of multiple folded internal limiting membrane (ILM) flap in the inverted ILM flap technique on postoperative outcomes of patients with full-thickness macular hole (FTMH).

Methods

This retrospective study included 41 eyes of 41 patients with FTMH treated with vitrectomy using the inverted ILM flap technique. Complete ophthalmic examination was performed preoperatively, at 1 week, and at 1, 3, 6, 9, and 12 months after surgery.

Results

Postoperative SD-OCT confirmed macular hole (MH) closure in all patients. The mean BCVA improved from 0.7 LogMAR (20/100) preoperatively to 0.5 LogMAR (20/63) postoperatively. In two cases, 7 days after vitrectomy, flap closure was noted. At the final visit after 12 months, the following foveal contours were noted: 14 U-shape (34.1%), 12 irregular (W-shape) (29.3%), and 6 V-shape (14.6%). We observed a type of “plug closure” in 9 (22%) eyes in which hyperproliferation was noted in one eye.

Conclusions

The surgeons should be aware of potential hyperproliferation on the retinal surface after the multi-layered flap technique.