ANATOMICAL AND VISUAL OUTCOMES OF INVERTED INTERNAL LIMITING MEMBRANE FLAP TECHNIQUE VERSUS INTERNAL LIMITING MEMBRANE PEELING IN MYOPIC MACULAR HOLE WITHOUT RETINAL DETACHMENT: A Preliminary Retrospective Study

Inverted flap technique versus internal limiting membrane insertion for macular hole in eyes with extremely high myopia

BACKGROUND

To compare the surgical outcomes of the inverted internal limiting membrane (ILM) flap technique and ILM insertion for macular hole (MH) without retinal detachment in eyes with extremely high myopia.

METHODS

In this retrospective study, we analyzed 22 eyes with an axial length ≥ 30.0 mm that had underwent MH surgery between April 2015 and August 2021. The surgical procedures involved either an inverted ILM flap or ILM insertion. The outcomes were compared between the two techniques. Closure of the MH was confirmed by optical coherence tomography (OCT). The best-corrected visual acuity (BCVA) was measured before and after surgery. Associated complications were documented.

RESULTS

The median of axial length was 30.64 mm (range, 30.0-34.42). The MH closed in 100% (22/22) eyes and did not recur with a median follow-up of 12.5 months. For the inverted ILM flap technique, the median BCVA improved significantly from 0.80 logarithm of the minimum angle of resolution (logMAR) (range, 0.40-2.00) before surgery to 0.70 logMAR (range, 0.09-1.52) after surgery (p = 0.002). In addition, the median of final BCVA was better for the inverted ILM flap than ILM insertion (0.7 logMAR V.S. 1.00 logMAR; p = 0.016).

CONCLUSIONS

In eyes with extremely high myopia, despite comparable effects on MH closure for both ILM insertion and the inverted ILM flap, the later technique achieved significantly better visual outcomes.

Biofeedback Training after Successful Inverted Internal Limiting Membrane (ILM)-Flap Technique for High Myopic Macular Hole

BACKGROUND

Microperimetric biofeedback training improved visual acuity and fixation stability in patients who previously underwent macular surgery. We aimed to compare the functional results of biofeedback training with the standard of care in patients who underwent successful inverted Internal Limiting Membrane (ILM)-flap technique for high myopic macular holes (hMMH).

METHODS

This was a retrospective, comparative, cohort study. Patients with hMMH after surgical hole closure underwent microperimetric biofeedback using structured light stimulus plus acoustic tone (n = 12; Biofeedback) or standard of care with scheduled visits (n = 11; Control). Best-corrected visual acuity, retinal sensitivity at central 12° (RS) and 4° (CRS) with a mean deviation at central 12° (MD), and fixation stability as bivariate contour ellipse area (BCEA 68%, 95%, and 99%) were assessed at baseline and month 1, 3, 6, and 12. The Mann-Whitney test was used to test the difference between the groups.

RESULTS

Baseline functional parameters were not significantly different among the groups. BCVA significantly improved in each group (Biofeedback, p = 0.002; Control, p ≤ 0.02) at all follow-up visits. CRS significantly improved at 6 (p = 0.03) and 12 (p = 0.01) months in the Biofeedback group and at month 12 (p = 0.01) in the Control group. RS (p = 0.001) and MD (p = 0.005) improved at the last follow-up only in the trained group. After training, BCEA 68% and 95% significantly improved (6 and 12 months, p < 0.05). The Biofeedback group had better results in RS (p ≤ 0.02), CRS (p ≤ 0.02), and BCEA 68%, 95%, and 99% (p ≤ 0.01) compared to the Control at all follow-ups. BCVA and MD were better in the Biofeedback group at month 3 (p = 0.01), and month 3 (p = 0.01) and 12 (p = 0.003), respectively.

CONCLUSIONS

Microperimetric biofeedback can increase retinal sensitivity and stabilize fixation better than the standard care over months after a successful inverted ILM-flap for hMMH.

Results of large macular hole surgery using different interposition techniques. A report on 9 cases

OBJECTIVE

To describe the long-term anatomical and functional restoration observed in patients operated on for a large macular hole (MH) using different macular interposition techniques.

METHOD

Retrospective analysis of the results obtained in a series of 9 patients undergoing large MH surgery (≥450μm) performing 4 different macular interposition techniques: inverted internal limiting membrane flap in 4 cases, autotransplantation of internal limiting membrane in 2, amniotic membrane graft in 2, and autologous anterior capsule graft in one. The mean follow-up time was 11 months. Anatomically, the outcome measures explored were the restoration of the outer layers of the retina and the pattern of MH closure. The final visual acuity and visual quality were functionally assessed.

RESULTS

The restoration of the outer layers was partial in 6 cases. The macular closure rate was 100%, showing an incomplete pattern in 4 cases. Visual acuity improved in 7 patients, remaining stable in 2. Three cases showed an eccentric fixation pattern and/or metamorphopsia.

CONCLUSIONS

The development of new surgical techniques has increased the rate of macular closure in large MHs. However, the anatomical and functional restoration remains unpredictable. In this work, macular closure was achieved in all patients and a higher rate of complete closure using inverted internal limiting membrane flap. The restoration of the outer layers was more favorable in the groups in which internal limiting membrane had been used. Functional recovery was independent of the technique used.

COMPARISON OF INTERNAL LIMITING MEMBRANE PEELING WITH THE INVERTED INTERNAL LIMITING MEMBRANE FLAP TECHNIQUE FOR RHEGMATOGENOUS RETINAL DETACHMENT COEXISTING WITH MACULAR HOLE

PURPOSE

To evaluate the anatomical and functional outcomes of internal limiting membrane (ILM) peeling and the inverted ILM flap technique for rhegmatogenous retinal detachment coexisting with macular hole.

METHODS

This retrospective study evaluated the medical records of 79 eyes with concurrent rhegmatogenous retinal detachment and macular hole received vitrectomy and silicone oil tamponade, with ILM peeling on 56 eyes and the inverted ILM flap technique on 23 eyes.

RESULTS

The Type 1 closure rate was greater in the inverted ILM flap group than the ILM peeling group (82.6% vs. 55.4%, P = 0.038). Lines of improvement were 7.8 ± 5.3 in the ILM peeling group and 8.9 ± 5.6 in the inverted ILM flap group. Postoperative epiretinal membrane and retinal reattachment rates were similar in two surgical groups (16.1% vs. 21.7%, P = 0.535 and 94.6% vs. 95.7%, P = 0.999, respectively). Type 1 closure was significantly correlated with the inverted ILM flap technique (OR = 5.568, P = 0.023). The inverted ILM flap technique showed no significant association with the final logarithm of the minimum angle of resolution best-corrected visual acuity in multivariate model analysis.

CONCLUSION

The inverted ILM flap technique was more effective in restoring the macular structure in patients with rhegmatogenous retinal detachment and coexisting macular hole, but the functional outcomes of the two strategies were comparable.

Inverted internal limiting membrane flap technique for retinal detachment due to macular holes in high myopia with axial length ≥ 30 mm

To compare the efficacy of internal limiting membrane (ILM) flap covering to that of ILM flap insertion for the treatment of macular hole retinal detachment (MHRD) in highly myopic eyes with axial length (AL) ≥ 30 mm. We retrospectively analysed the medical records of 48 MHRD patients with high myopia (AL ≥ 30 mm). According to different surgical methods, the patients were divided into a covering group (23 eyes) and an insertion group (25 eyes). The rate of retinal reattachment and MH closure were compared between the two groups, and the related factors affecting the initial anatomical results were analysed. After primary vitrectomy and single silicone oil removal, there were 18 eyes (78.3%) in the covering group, and 20 eyes (80.0%) in the insertion group had retinal reattachment (P = 1.000). Moreover, 16 eyes (69.6%) in the covering group and 17 eyes (68.0%) in the insertion group had their MHs sealed (P = 0.907). The best-corrected visual acuity (BCVA) at 12 months and the improvement in BCVA postoperatively in the two groups were not statistically significant (P = 0.543, 0.955). Logistic regression analysis showed that elongated AL (OR = 1.844, 95% CI 1.037–3.280, P = 0.037) and higher choroidal atrophy (OR = 2.986, 95% CI 1.011–8.821, P = 0.048) were risk factors affecting initial anatomical success. For extremely high-myopia MHRD with AL ≥ 30 mm, ILM flap covering and insertion can both effectively seal the MH and promote retinal reattachment, but the visual function improvement may still be limited. The longer the AL and the higher the choroidal atrophy, the greater is the risk of initial anatomical failure.

Inverted Internal Limiting Membrane Flap Technique: Is It the Best Option for Macular Holes?

Surgical treatment is generally necessary to repair full-thickness macular holes (FTMH). Although vitrectomy with or without internal limiting membrane (ILM) peeling remains the standard surgical technique, the inverted ILM flap procedure has increasingly assumed a role in the primary surgical repair of FTMHs. Some vitreoretinal surgeons reserve this technique to treat large or myopic holes, whereas others use it routinely in all cases. This paper is a comprehensive review of the current scientific evidence on the anatomical and functional outcomes of the inverted ILM flap technique in the repair of macular holes, following the International Vitreomacular Traction Study (IVTS) group classification.

Current management strategies for atypical macular holes

This review evaluates the current surgical management options for refractory and atypical macular holes (MH) and proposes a treatment paradigm for approaching complex cases. A review of literature was performed to deliver a thorough discussion of the epidemiology and pathophysiology of MH as well as the historic evolution of surgical management strategies. With this context established, an update on recent surgical advances for management of large, chronic, and highly myopic MH is provided. New small MH may be adequately treated with pars plana vitrectomy, while those ≥300 μm should undergo internal limiting membrane (ILM) peel. For MH ≥400 μm with risk factors for failure, primary intervention should involve creation of an ILM flap and various methods of flap creation are discussed. For very large MH ≥700 μm or in refractory cases, autologous retinal transplants and other recently proposed procedures should be considered. While typical MHs enjoy high initial surgical success rates, atypical and refractory MH require additional intraoperative and postoperative considerations to maximize surgical success and optimize vision. With many techniques at the surgeon's disposal, patient selection becomes critical to improving outcomes.

Complete ILM Peeling Versus Inverted Flap Technique for Macular Hole Surgery: A Meta-Analysis

BACKGROUND AND OBJECTIVE

To compare complete internal limiting membrane (ILM) peeling with the inverted flap technique for macular hole (MH) surgery.

PATIENTS AND METHODS

An electronic database search on PubMed, CENTRAL, and ClinicalTrials.gov was performed. Inclusion criteria were comparative prospective/retrospective studies including patients with MH of any size with at least 6 months of follow-up. The primary outcome was MH closure rate. Secondary outcomes were best-corrected visual acuity improvement and surgery-related adverse events.

RESULTS

Sixteen papers enrolling 1,403 eyes were included (733 ILM peeling, 670 inverted flap). MH mean minimum diameter and time of symptomatic evolution were higher in the inverted flap group (531.1 μm ± 188.8 μm vs. 602.8 μm ± 223.8 μm; 10.4 ± 20.2 months vs. 12.0 ± 18.4 months; P < .01). Overall, MH closure rate was superior with the inverted flap technique (risk-ratio [RR]: 1.25; 95% confidence interval [CI], 1.14-1.38; P < .0001), as well as in all subgroups: idiopathic large MH (n = 362; RR: 1.12; 95% CI, 1.05-1.20; P < .001), myopic MH without retinal detachment (n = 133; RR: 1.35; 95% CI, 1.14-1.59; P < .001), and MH retinal detachment (n = 198; RR: 1.89; 95% CI, 1.31-2.73; P < .001).

CONCLUSION

This meta-analysis suggests the inverted flap technique is more effective in achieving MH closure. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:187-195.].

Inverted internal limiting membrane flap technique for myopic macular hole: A meta-analysis

A macular hole (MH) may be a significant complication in patients with high myopia. The recently reported inverted internal limiting membrane (ILM) flap technique is a promising alternative to treat myopic MHs. We performed a meta-analysis of the published anatomical and functional results of the "inverted ILM flap" technique for the treatment of myopic MH with or without retinal detachment (RD). Our results showed that the inverted ILM flap technique, either covering or insertion, is an effective method for treating myopic MH with or without RD and provides high MH closure, ranging from 91.8% to 97.1%. Despite the high MH closure rate, the pooled visual acuity improvement rate was 77.3% and 66.2% in patients with myopic MH without RD, while it was 95% and 80.3% in patients with myopic MHRD, using "covering" and "insertion" ILM flap technique, respectively. Potential complications included reopening or persistence of MH, development of RD, choroidal detachment, ocular hypertension, and chorioretinal atrophy.

Internal limiting membrane flap technique in macular hole surgery

Vitrectomy combined with internal limiting membrane (ILM) peeling is popular for the treatment of macular hole (MH). However, the improvements of MH closure rate and postoperative visual acuity are not satisfactory especially in large and refractory MHs. Currently, the ILM flap technique has gradually been applied for the treatment of MH and achieved high MH closure rate. The ILM flap technique has many variations, including the difference of the size, shape, number, and manner in which the flaps put on the MHs. The ILM flap technique also has some auxiliary means including perfluoro-n-octane (PFO), dye, autologous blood and adhesive viscoelastics. There is controversy about the effects between several technique variations of ILM flap, and it needs to be explored in the future.

Comparison of Anatomical and Visual Outcomes between Idiopathic and Myopic Macular Holes Using the Internal Limiting Membrane or Inverted Internal Limiting Membrane Flap Technique

Purpose

To compare the results of vitrectomy with those of internal limiting membrane (ILM) peeling or inverted ILM flap for treating myopic or idiopathic macular hole.

Methods

Thirty-nine eyes of 39 patients undergoing vitrectomy with ILM peeling for macular hole (25 idiopathic and 14 myopic) and 27 eyes of 27 patients undergoing vitrectomy with inverted ILM flap (15 idiopathic and 12 myopic) were included. Outcome measures were macular hole closure by optical coherence tomography and visual acuity at 6 months.

Results

Closure was achieved in 25 (100%) idiopathic and 12 (86%) myopic macular holes in the ILM peeling group and in 14 (93%) idiopathic and 11 (91.77%) macular holes in the inverted ILM flap group. There were no statistically significant differences in restoration of the external limiting membrane and ellipsoid zone between the groups. Median best-corrected visual acuity (logarithm of minimal angle of resolution) at the end of follow-up was 0.22 (20/32 Snellen) in idiopathic and 0.4 (20/50) in myopic (P=0.042) patients in the ILM peeling group and 0.4 (20/50) in idiopathic and 0.4 (20/50) in myopic (P=0.652) patients in the inverted ILM flap group.

Conclusion

Both techniques were associated with high closure rates in myopic and idiopathic macular holes, with somewhat better visual outcomes in idiopathic cases. The small sample size may have provided insufficient power to support the superiority of one technique over the other in the two groups.