EFFECT OF INVERTED INTERNAL LIMITING MEMBRANE FLAP ON CLOSURE RATE, POSTOPERATIVE VISUAL ACUITY, AND RESTORATION OF OUTER RETINAL LAYERS IN PRIMARY IDIOPATHIC MACULAR HOLE SURGERY

Modified ILM flap techniques versus classical inverted ILM flap technique for large macular holes: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Macular holes (MHs) constitute a vitreoretinal interface disorder that occurs when structural abnormalities in the fovea lead to impaired central vision. The standard treatment for MHs is mainly surgical. Using an inverted internal limiting membrane (ILM) flap has enhanced the success rates of MH surgeries. This systematic review and meta-analysis aimed to compare the classical inverted ILM flap technique to modified ILM flap techniques for managing large MHs.

METHODS

We searched Medline, Embase, and CENTRAL. We included randomized controlled trials (RCTs) that compared the classic inverted ILM flap technique to modified ILM flap techniques as initial surgical treatment of eyes with large MHs of more than 400 microns. We sought to evaluate the following outcomes: (1) MH closure. (2) Best-corrected visual acuity (BCVA). (3) Foveal closure type (4) Rate of ellipsoid zone (EZ) defects and external limiting membrane (ELM) defects. The standardized mean difference (SMD) was used to represent continuous outcomes, while the risk ratio (RR) was used to represent dichotomous outcomes.

RESULTS

Four RCTs that enrolled 220 participants were deemed eligible. The analysis revealed no statistically significant differences in MH closure between both groups (95% CI: 0.20, 7.96; P = 0.81). No statistically significant differences in mean BCVA were found at 1 and 3 months between both groups (SMD: 0.04; 95% CI: -0.16, 0.23; P = 0.70 and SMD: -0.167; 95%CI: -1.240, 0.906; P = 0.760, respectively). In addition, there were no significant differences between the two groups in the pattern of foveal closure, namely U-shape, V-shape, and flap open at 3, 6, and 12 months (RR: 0.87; 95% CI: 0.67, 1.12; P = 0.28, RR: 0.96; 95% CI: 0.58, 1.61; P = 0.89, and RR: 1.95, 95% CI: 0.26, 14.50; P = 0.51, respectively). Finally, the analysis showed no statistically significant difference in both groups' EZ and ELM defect rates at 3, 6, and 12 months (RR: 1; 95% CI: 0.85; 1.18: P = 1 and RR: 1.14; 95% CI: 0.90, 1.45; P = 0.27).

CONCLUSION

Macular holes (MHs) constitute a vitreoretinal interface disorder that occurs when structural abnormalities in the fovea lead to impaired central vision. The standard treatment for MHs is mainly surgical. Using an inverted internal limiting membrane (ILM) flap has enhanced the success rates of MH surgeries. This systematic review and meta-analysis aimed to compare the classical inverted ILM flap technique to modified ILM flap techniques for managing large MHs.

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.

Presence of subfoveal hyperreflective dots as an anatomic and functional prognostic biomarker in macular holes

OBJECTIVE

To evaluate the presence of subfoveal hyperreflective dots (SfHD) using optical coherence tomography (OCT) in macular holes (MH) and establish whether there is a relationship with postoperative anatomical and functional outcomes.

METHODS

An observational cross-sectional study was conducted at the Dr. Elías Santana Hospital. Sixty-eight eyes of 67 patients with a tomographic diagnosis of full-thickness MH who underwent pars plana vitrectomy (PPV) and internal limiting membrane (ILM) peeling were included. Preoperative and postoperative measurements were obtained using radial macular scans and HD raster scans with Optovue and Cirrus 5000 (Zeiss) OCT machines. The main outcome measures were anatomical closure by OCT and functional outcome through best-corrected visual acuity (BCVA).

RESULTS

The anatomical closure rate in our study was 63%. MHs that failed to achieve anatomical closure exhibited a higher number of hyperreflective dots and worse postoperative BCVA. A statistically significant association was found between exposed retinal pigment epithelium (RPE) in microns and the number of SfHD (P = .001).

CONCLUSION

SfHD is a common tomographic finding in MH, and the presence of a higher number of these points is associated with poorer anatomical and functional outcomes. This imaging finding is a potential prognostic biomarker in this pathology.

Biological ultrathin amniotic membrane flap to close refractory macular holes associated with high myopia

PURPOSE

To propose an ultrathin biological amniotic membrane (btAM) thinner than 10 μm as the graft to treat highly myopic macular holes (MH).

METHODS

This pilot study included 14 patients affected by refractory macular holes associated with high myopia. btAM was used as a bandage covering the holes. The best-corrected visual acuity (BCVA), fundus photography, and optical coherence tomography (OCT) before and after surgery were compared.

RESULTS

The mean MH size was 865.93 ± 371.72 μm and all the MHs achieved anatomical closure. The btAM located centrally and fully on MHs from fundus photography yet no obvious visual masking was complained. The average BCVA 1 month, 3, and 6 months after surgery were 0.95 ± 0.24, 0.92 ± 0.23, 0.92 ± 0.23 logMAR, respectively, improved significantly compared to pre-operative BCVA (1.24 ± 0.42 logMAR, all P < 0.05). Ten out of 14 (71.4%) exhibited 2C closure patterns (formally closed and no bare RPE) on OCT.

CONCLUSION

The btAM thinner showed a favorable anatomical success with less risk of parafoveal atrophy or iatrogenic injuries and shortened the dissolving time.

A COMPARATIVE STUDY OF MEDIUM-SIZED MACULAR HOLE SURGERY WITH INVERTED INTERNAL LIMITING MEMBRANE FLAP TECHNIQUE VERSUS CONVENTIONAL PEELING

PURPOSE

To investigate surgical results for medium-sized (251-400 µ m) macular holes (MHs).

METHODS

This retrospective observational study involved 266 eyes of 262 consecutive patients who underwent internal limiting membrane (ILM) peeling (147 eyes in the ILM peeling group) or inverted ILM flap cover technique (119 eyes in the inverted flap group) for primary medium-sized full-thickness MHs. Macular hole associated with retinal detachment, recurrent MH, and traumatic MH were excluded.

RESULTS

The primary closure rate for overall medium-sized MHs was 100% (119 of 119 eyes) in the inverted flap group, which was significantly higher than that (94.6% [139/147 eyes]; P = 0.010) in the ILM peeling group. Notably, even after adjusting for the minimum MH diameter, presence of high myopia, or preexisting posterior vitreous detachment, the primary closure rate was significantly better in the inverted flap group than in the ILM peeling group (Cochran-Mantel-Haenszel test, overall adjusted P = 0.006, 0.009, 0.005, respectively). The preoperative and postoperative restoration of the outer retinal layers and visual acuity were comparable between the inverted ILM flap and ILM peeling techniques.

CONCLUSION

Primary closure for medium-sized MHs was significantly superior in the inverted flap group than in the ILM peeling group.

Internal Limiting Membrane Peeling and Inverted Flap Technique in Macular Hole: Postoperative Metamorphopsia and Optical Coherence Tomography

INTRODUCTION

We compared postoperative metamorphopsia and optical coherence tomography (OCT) findings between eyes that underwent internal limiting membrane (ILM) peeling and the inverted flap (IF) technique for macular hole (MH).

METHODS

This retrospective analysis included 64 eyes of 64 patients with idiopathic MH whose MH was closed after initial surgery. Thirty-nine patients were treated with pars plana vitrectomy (PPV) with ILM peeling, and 25 patients were treated with PPV with the IF technique. Best corrected visual acuity (BCVA), severity of metamorphopsia, and OCT images were collected before and 3, 6, and 12 months postoperatively. Based on the OCT images, the status of the external limiting membrane (ELM) and ellipsoid zone and the presence of hyperreflective plugs were assessed.

RESULTS

At baseline and 3, 6, and 12 months postoperatively, BCVA and severity of metamorphopsia were not significantly different between groups. The status of the ELM was significantly worse in the IF group than in the ILM peeling group at 3 and 6 months postoperatively. Significantly more hyperreflective plugs were observed in the IF group than in the ILM peeling group at 3 and 6 months postoperatively. Stepwise multiregression analysis revealed that hyperreflective plugs were significantly associated with the severity of metamorphopsia at 12 months postoperatively.

DISCUSSION/CONCLUSION

The alterations on the OCT were fewer in the ILM peeling group than in the IF group, while no significant differences were observed in postoperative severity of metamorphopsia between groups. Metamorphopsia was worse in eyes with hyperreflective plugs.

Prediction of foveal microstructure and visual outcomes following surgery for idiopathic macular hole: An assessment using spectral-domain optical coherence tomography

PURPOSE

To evaluate the efficacy of two novel indices, the hole closure index (HCI) and the hole healing index (HHI), in predicting both the anatomic outcome and postoperative visual acuity following surgical intervention for idiopathic macular holes.

METHODS

A total of 38 patients diagnosed with idiopathic macular hole (IMH) were included. All patients underwent standard surgical treatment, including vitrectomy, internal limiting membrane (ILM) peeling, and gas tamponade. Preoperative and postoperative spectral-domain optical coherence tomography (SD-OCT) was utilized to assess the anatomical status of the macular hole (MH). The maximum distance between the tips of the external limiting membrane (ELM) was designated as the hole size (HS). HHI, calculated as the ratio of hole height to HS, and HCI, calculated as the ratio of hole height to the average of minimum diameter and base diameter, were determined. Postoperative reconstruction of ELM and ellipsoid zone (EZ) was evaluated, along with analysis of best-corrected visual acuity (BCVA) on a logarithm of the minimum angle of resolution (logMAR) scale. Regression analysis was performed to evaluate the relationship between anatomical outcomes, postoperative visual acuity, and optical coherence tomography (OCT) parameters. Receiver operating characteristic (ROC) curves were generated for both HHI and HCI.

RESULTS

Regression analyses revealed significant correlations between HCI and the restoration of ELM and EZ at 6 months after surgery (P = 0.002 and P = 0.014, respectively). In addition, a significant correlation was found between HHI and postoperative BCVA better than logMAR 0.52 also at 6 months after surgery (P = 0.033). The area under the ROC curve (AUC) for HCI based on ELM and EZ reconstruction was high, with values of 0.942 and 0.842, respectively. AUC for HHI, determined by ROC curve analysis of postoperative BCVA, was 0.704.

CONCLUSIONS

In conclusion, our findings indicate that HCI may be the most accurate predictor of type 1 closure, while HHI could be considered a potential predictor of postoperative visual acuity.

VERTICAL AND HORIZONTAL METAMORPHOPSIA ONE YEAR AFTER SURGERY FOR MACULAR HOLES ≤ 500 µ m WITH AND WITHOUT INVERTED INTERNAL LIMITING MEMBRANE FLAP

PURPOSE

To investigate the effect of an inverted internal limiting membrane flap (IF) and other factors on metamorphopsia after macular hole surgery.

METHODS

Prospective case series of patients undergoing pars plana vitrectomy with gas tamponade, with either conventional internal limiting membrane peeling (CP) or an IF, for primary idiopathic macular holes ≤ 500 µ m. Vertical and horizontal metamorphopsia were measured as M-scores (degrees) using M-charts preoperatively and at 2, 6, and 12 months postoperatively.

RESULTS

Fifty-three eyes of 53 patients were included of whom 27 underwent CP and 26 were treated with an IF. After macular hole surgery, all patients were pseudophakic. Vertical and horizontal metamorphopsia improved from 1.08 (±0.51) and 0.98 (±0.70) preoperatively to 0.58 (±0.37) and 0.45 (±0.36) at 2 months ( P < 0.01), with no further significant improvement at 6 months (0.39 [±0.31], P = 0.07 and 0.31 [±0.28], P = 0.18) or at 12 months (0.37 [±0.30], P = 0.72 and 0.28 [±0.28], P = 0.99). There was no significant difference in the mean vertical and horizontal metamorphopsia between patients with CP and with an IF at 2 months ( P = 0.063, P = 0.10), 6 months ( P = 0.25, P = 0.16), or 12 months ( P = 0.62, P = 0.22). Preoperative vertical M-score improved at 12 months after macular hole surgery by 61% and 64% in the CP and IF groups, respectively ( P = 0.84), and the horizontal M-score by 65% and 71%, respectively ( P = 0.98).

CONCLUSION

The use of an IF has no evident bearing on the degree of postoperative metamorphopsia 12 months after surgical repair of macular holes ≤ 500 µ m.

Surgical Management of Full-Thickness Macular Holes in Macular Telangiectasia Type 2: A Global Multicenter Study

PURPOSE

To report on macular hole repair in macular telangiectasia type 2 (MacTel2).

DESIGN

Global, multicenter, retrospective case series.

PARTICIPANTS

Patients undergoing surgery for MacTel2-associated full-thickness macular hole (MTMH).

METHODS

Standardized data collection sheet distributed to all surgeons.

MAIN OUTCOME MEASURES

Anatomic closure and visual outcomes of MTMH.

RESULTS

Sixty-three surgeries in 47 patients with MTMH were included from 30 surgeons. Mean age was 68.1 years, with 62% female, 72% White, 21% East or South Asian, 2% African American, and 2% Hispanic or Latino. Procedures included 34 internal limiting membrane (ILM) peeling alone, 22 ILM flaps, 5 autologous retinal transplantations (ARTs), 1 retinotomy, and 1 subretinal bleb. For ILM peeling, preoperative visual acuity (VA) was 0.667 ± 0.423 logarithm of the minimum angle of resolution (logMAR). Minimum hole diameter (MHD) was 305.5 ± 159.4 μm (range, 34-573 μm). Sixteen of 34 ILM peels (47%) resulted in MTMH closure. At postoperative month 6, VA was stable at 0.602 ± 0.516 logMAR (P = 0.65). VA improved by at least 2 lines in 43% and at least 4 lines in 24%. For ILM flaps, preoperative VA was 0.878 ± 0.552 logMAR. MHD was 440.8 ± 175.5 μm (range, 97-697 μm), which was significantly larger than for ILM peels (P < 0.01). Twenty of 22 ILM flaps (90%) resulted in MTMH closure, which was significantly higher than for ILM peels (P < 0.01). At postoperative month 6, VA improved to 0.555 ± 0.405 logMAR (P < 0.05). VA improved by at least 2 lines in 56% and at least 4 lines in 28%. For ARTs, preoperative VA was 1.460 ± 0.391 logMAR. MHD was 390.2 ± 203.7 μm (range, 132-687 μm). All 5 ARTs (100%) resulted in MTMH closure. At postoperative month 6, VA was stable at 1.000 ± 0.246 logMAR (P = 0.08). Visual acuity improved at least 2 lines in 25%.

CONCLUSIONS

Surgical closure of macular holes improved VA in 57% of MTMHs. Internal limiting membrane flaps achieved better anatomic and functional outcomes than ILM peeling alone. Autologous retinal transplantation may be an option for refractory MTMHs.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

MicroRNA-152-3p and MicroRNA-196a-5p Are Downregulated When Müller Cells Are Promoted by Components of the Internal Limiting Membrane: Implications for Macular Hole Healing

Müller cells play a critical role in the closure of macular holes, and their proliferation and migration are facilitated by the internal limiting membrane (ILM). Despite the importance of this process, the underlying molecular mechanism remains underexplored. This study investigated the effects of ILM components on the microRNA (miRNA) profile of Müller cells. Rat Müller cells (rMC-1) were cultured with a culture insert and varying concentrations of ILM component coatings, namely, collagen IV, laminin, and fibronectin, and cell migration was assessed by measuring cell-free areas in successive photographs following insert removal. MiRNAs were then extracted from these cells and analyzed. Mimics and inhibitors of miRNA candidates were transfected into Müller cells, and a cell migration assay and additional cell viability assays were performed. The results revealed that the ILM components promoted Müller cell migration (p < 0.01). Among the miRNA candidates, miR-194-3p was upregulated, whereas miR-125b-1-3p, miR-132-3p, miR-146b-5p, miR-152-3p, miR-196a-5p, miR-542-5p, miR-871-3p, miR-1839-5p, and miR-3573-3p were significantly downregulated (p < 0.05; fold change > 1.5). Moreover, miR-152-3p and miR-196a-5p reduced cell migration (p < 0.05) and proliferation (p < 0.001), and their suppressive effects were reversed by their respective inhibitors. In conclusion, miRNAs were regulated in ILM component-activated Müller cells, with miR-152-3p and miR-196a-5p regulating Müller cell migration and proliferation. These results serve as a basis for understanding the molecular healing process of macular holes and identifying potential new target genes in future research.

Anatomical and functional results after vitrectomy with conventional ILM peeling versus inverted ILM flap technique in large full-thickness macular holes

BACKGROUND

Aim of the study was to compare success rate and functional outcome following pars plana vitrectomy (PPV) with conventional internal limiting membrane (ILM) peeling versus ILM flap technique for full-thickness idiopathic macular holes (FTMH).

METHODS

Retrospective analysis of consecutive eyes with FTMH having undergone vitrectomy with sulfur hexafluoride (SF6) endotamponade 25% at the University Medical Center Rostock, Germany (2009-2020). Eyes were divided according to applied surgical technique (ILM peeling [group P] versus ILM flap [group F]). Inclusion criteria were macular hole base diameters (MH-BD) ≥ 400 μm plus axial length ≤ 26.0 mm. Each group was divided into two subgroups based on macular hole minimum linear diameter (MH-MLD): ≤ 400 μm and > 400 μm. Exclusion criteria were FTMH with MH-BD < 400 μm, trauma, myopia with axial length > 26.0 mm or macular schisis. Demographic, functional, and anatomical data were obtained pre- and postoperatively. Preoperative MH-BD and MH-MLD were measured using optical coherence tomography (OCT; Spectralis®, Heidelberg Engineering GmbH, Heidelberg, Germany). Main outcome parameter were: primary closure rate, best-corrected visual acuity (BCVA), and re-surgery rate.

RESULTS

Overall 117 eyes of 117 patients with FTMH could be included, thereof 52 eyes underwent conventional ILM peeling (group P) and 65 additional ILM flap (group F) technique. Macular hole closure was achieved in 31 eyes (59.6%) in group P and in 59 eyes (90.8%) in group F (p < 0.001). Secondary PPV was required in 21 eyes (40.4%) in group P and in 6 eyes (9.2%) in group F. Postoperative BCVA at first follow-up in eyes with surgical closure showed no significant difference for both groups (MH-MLD ≤ 400 μm: p = 0.740); MH-MLD > 400 μm: p = 0.241).

CONCLUSION

Anatomical results and surgical closure rate following ILM flap technique seems to be superior to conventional ILM peeling for treatment of FTMH.

Prognostic factors for visual recovery after successful large macular hole surgery using the inverted flap technique

PURPOSE

The goal of our study is to describe the functional results and preoperative factors predicting visual recovery after successful inverted flap technique and closure of large full-thickness macular holes (FTMH) and to evaluate the correlations between microstructural foveal changes and final visual acuity.

METHODS

Retrospective, descriptive, analytical study including 80 eyes of 78 patients with large FTMH; operated by inverted flap technique with successful closure of the macular hole after surgery. All eyes underwent a full preoperative ophthalmic examination and macular B-scan SD-OCT. We performed the classic inverted flap technique for all patients. Postoperatively, all patients were examined at 7 days, 1, 3, 6, 9 and 12 months after surgery. SD-OCT was performed for all patients on each follow-up. Preoperatively, best-corrected visual acuity (BCVA), FTMH size and basal hole diameter were the main outcome measures. Postoperatively, BCVA, macular thickness, integrity of the external limiting membrane (ELM) and ellipsoid zone (EZ) were recorded.

RESULTS

Mean age was 62±8.42 years with female predominance. Mean size of the FTMH was 692.59μm, and mean basal hole diameter was 1436.06μm. Mean BCVA improved from 1.06±0.491 LogMAR preoperatively to 0.52±0.32 at 9 months following surgery (P<0.001). At 9 months, the ELM was absent, partial or fully restored in 6.67, 10 and 83.33% respectively. The EZ was absent, partial or fully restored in 6.67, 33 and 63.33% respectively. ELM regeneration always preceded EZ regeneration at every point of follow-up. Final BCVA was statistically correlated with initial hole size (P=0.006, OR=1.056; CI [1.016-1.098]) and mean symptom duration prior to surgery (P=0.001. OR=0.987; CI [0.976-0.998]). Analysis of the ROC curve demonstrated that a hole diameter>478.5μm and symptom duration>5 weeks were correlated with non-improvement of visual acuity, with 81.3% sensibility and 18.7% specificity.

CONCLUSION

We report tomographic microstructural foveal changes and functional results following successful large idiopathic FTMH surgery using the classic inverted flap technique. Preoperative parameters such as initial FTMH diameter and mean symptom duration prior to surgery are crucial prognostic factors influencing final visual results.

DIFFERENCES IN ANATOMICAL AND VISUAL OUTCOMES AMONG THREE INTERNAL LIMITING MEMBRANE TECHNIQUES TREATING EXTRA-LARGE IDIOPATHIC MACULAR HOLES

PURPOSE

To compare the anatomical and visual outcomes of extra-large idiopathic macular holes treated with internal limiting membrane peeling and two inverted internal limiting membrane flap techniques, namely insertion and cover technique.

METHODS

Patients with idiopathic macular holes (minimum linear diameter ≥ 650 µm) were divided into peeling group, insertion group, and cover group. The initial closure rate, final length of external limiting membrane and ellipsoid zone recovery, and best-corrected visual acuity were evaluated.

RESULTS

A total of 124 eyes were included, and the average follow-up was 7.2 months. All the baseline characteristics were comparable among the three groups. Initial closure rate of the peeling group, the insertion group, and the cover group was 65.0% (26/40), 97.6% (41/42), and 90.5% (38/42), respectively (P < 0.001). In closed idiopathic macular holes, the peeling group and the cover group exhibited significantly longer length of external limiting membrane recovery than the insertion group (P < 0.001), and the peeling group exhibited significantly longer length of ellipsoid zone recovery than the other two groups (P = 0.021). The peeling group and the cover group exhibited significantly better best-corrected visual acuity improvement than the insertion group (P = 0.009).

CONCLUSION

For extra-large idiopathic macular holes, cover technique surpasses internal limiting membrane peeling technique in closure rate and outperforms insertion technique in anatomical and functional recovery, whereas insertion technique may adversely affect the recovery of foveal microstructure and best-corrected visual acuity.

Surgical classification for large macular hole: based on different surgical techniques results: the CLOSE study group

BACKGROUND

The CLOSE study group proposes an updated surgical classification for large macular holes based on a systematic review of new treatments. Recently, many new techniques have been introduced to treat large full-thickness macular holes (FTMH); although the indications are not clear. An updated surgical classification is needed to help surgical decision-making.

METHODS

We gathered published series by the CLOSE Study Group members and from literature search until June 2021. Techniques included: internal limiting membrane peeling (ILM peeling), ILM flaps, macular hydrodissection (macular hydro), human amniotic membrane graft (hAM), and autologous retinal transplantation (ART). Within each technique, chi-square test assessed association between the minimal linear diameter (MLD) (in µm) and closure rate; the postoperative best-corrected visual acuity (BCVA) gains were compared among groups.

RESULTS

Data extraction included 31 published articles: total of 1135 eyes. Eyes were divided into the following groups: ILM peel (n: 683), ILM Flap (n: 233), macular hydrodissection (n: 64), hAM (n: 59), and ART (n: 96). The initial BCVA and size were heterogenous between the groups. ILM peel showed the best results in large FTMH ≤ 535 µm (closure rate 96.8%); adjusted mean BCVA: 0.49 (LogMAR) with a statistical difference among groups. Large FTMH between 535 and 799 µm: ILM flap technique showed better results (closure rate 99.0%); adjusted mean BCVA: 0.67(LogMAR); also with a statistical difference. For large FTMH ≥ 800 µm more invasive techniques are required. Use of hAM, macular hydrodissection and ART showed higher closure rates for this category (100%, 83.3% and 90.5% respectively), and adjusted mean BCVA varied from 0.76 to 0.89. Although there was no statistical difference between those techniques for this group due to the smaller number of cases.

CONCLUSIONS

The CLOSE study group demonstrated the potential usefulness of a new surgical classification for large FTMHs and propose OCT biomarkers for use in clinical practice and future research. This new classification demonstrated that Large (400-550 µm) and X-Large (550-800 µm) holes can be treated highly successfully with ILM peel and ILM flap techniques, respectively. Further studies are necessary for the larger FTMHs (XX-Large and Giant), using the CLOSE classification, in order to determine which technique is better suited for each hole size and characteristics.

Internal Limiting Membrane Peeling and Gas Tamponade For Full-Thickness Macular Holes of Different Etiology - Is It Still Relevant?

Background

Despite the abundance of novel surgical approaches proposed for full thickness macular hole (FTMH) treatment, the choice of the optimal technique remains debatable Vitrectomy with «classic» internal limiting membrane peeling and gas tamponade remains the standard of FTMH surgery in many cases, but there are still very limited recent publications on the outcomes of such surgery.

Purpose

To investigate the anatomical and functional result and to analyze the significance of outcome-related risk factors of the classic 25-gauge pars plana vitrectomy (PPV) with ILM peeling and gas tamponade (GT) for treatment of FTMH of different etiology.

Patients and methods

Thirty-eight eyes of thirty-seven patients with FTMH who underwent 25-gauge PPV, ILM peeling and GT were recruited for this retrospective, consecutive, interventional study. Four eyes with persistent holes underwent a re-operation. Outcome-related factors were discussed.

Results

The primary closure rate was 89.5% (34/38). All eyes that underwent the repeated surgery (4 cases) obtained final closure. A hole size of >500 μm has a statistically significant effect on the primary macular hole closure (F = 0.048; φ = 0.38; p ˂ 0.05). In the general group (N = 38), the duration of symptoms directly correlated with age (ρ = 0.34; p = 0.04), size of the hole (ρ = 0.66; p ˂ 0.001) and BCVA before surgery (ρ = 0.59; p ˂ 0.001), after 1 month (ρ = 0.36; p = 0.03), and after 3 months (ρ = 0.35; p = 0.03). Preoperative BCVA was better in initially closed cases (Group 1) (U = 26.0; p = 0.05). In the Group 2 with primary unclosed holes, 75% of the eyes (3/4) had an axial length (AL) >26 mm, while in Group 1 such eyes were 12.5 times less (2/34) 5.9% (F = 0.004; φ = 0.63; р ˂ 0.01). The ELM recovery rate at 3 months was 92% (35/38 eyes) and the restoration of EZ at 3 months was 47% (18/38 eyes). Best-corrected visual acuity of all individuals improved significantly from 0.72 ± 0.35 (logMAR) (Me = 0.7; IQR: 0.5-0.8) to 0.25±0.14 (logMAR) (Me = 0.2; IQR: 0.2 - 0.3) at 1 month and 0.17 ± 0.13 (logMAR) (Me = 0.2; IQR: 0.1 - 0.2) at 3 months after surgery (P = 0.0001).

Conclusion

25G PPV with ILM and GT for FTMH of different etiology provide satisfactory morphologic and functional outcomes. Elongated AL, large diameter of MH and long duration of symptoms are the risk factors for initial closure. Proper second surgery can obtain satisfactory outcomes for persistent holes.

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.

Single-Layer Inverted Internal Limiting Membrane Flap Versus Conventional Peel for Small- or Medium-Sized Full-Thickness Macular Holes

PURPOSE

To analyze the outcomes of using an internal limiting membrane (ILM) flap and the conventional ILM peel technique for small- or medium-sized full-thickness macular hole (FTMH) repair.

DESIGN

Retrospective, interventional case series.

METHODS

Eyes with an FTMH ≤400 µm that underwent vitrectomy with a single-layer inverted ILM flap (flap group, 55 eyes) or an ILM peel (peel group, 62 eyes) were enrolled. Best-corrected visual acuity (BCVA) and optical coherence tomography (OCT) measurements were obtained preoperatively and at 1, 3, 6, and 12 months postoperatively.

RESULTS

Primary hole closure was achieved in 54 (98%) and 60 (97%) eyes in the flap and peel groups, respectively. The preoperative and postoperative 12-month BCVA values were comparable between the groups but were significantly better in the flap than in the peel group at 1 month (mean ± SD logMAR: 0.83 ± 0.43 vs 1.14 ± 0.50; P = .001), 3 months (0.58 ± 0.33 vs 0.82 ± 0.43; P = .002), and 6 months (0.56 ± 0.32 vs. 0.72 ± 0.48; P = .028). In the flap group, foveal gliosis was less common than in the peel group at 1 month (P = .030), and restored external limiting membrane and interdigitation zone was more common at 3 months (P = .046 and P < .001, respectively).

CONCLUSIONS

The single-layer ILM flap and conventional ILM peel techniques both closed FTMHs and improved vision. ILM flaps were associated with better visual outcomes up to 6 months postoperatively and should be considered in FTMHs ≤400 µm.

360° inverted internal limiting membrane flap technique for idiopathic macular holes ≤ 250 µm, > 250 and ≤ 400 µm, and > 400 µm

PURPOSE

To study the functional and morphological results of the inverted internal limiting membrane (ILM) flap technique for the treatment of idiopathic macular holes (MHs) sized ≤ 250 µm, > 250 and ≤ 400 µm, and > 400 µm.

METHODS

Retrospective, nonrandomized interventional study of 65 eyes with primary idiopathic MHs who underwent pars plana vitrectomy (PPV) with the inverted ILM flap technique. Closure rate, best-corrected visual acuity (BCVA), and integrity of external limiting membrane (ELM) and ellipsoid zone (EZ) were analyzed by optical coherence tomography (OCT).

RESULTS

Total closure rate was 96.9% with 100% in the ≤ 250 µm group, 100% in the > 250 and ≤ 400 µm group, and 91.7% in the > 400 µm group. Mean BCVA significantly improved after treatment: from 0.7 to 0.3 LogMAR in the ≤ 250 µm group (n = 15, p < 0.001), from 0.9 to 0.4 LogMAR in the > 250 and ≤ 400 µm group (n = 26, p < 0.001), and from 1.0 to 0.5 LogMAR in the > 400 µm group (n = 24, p < 0.001). A total of 16 patients had follow-up over 14 months: BCVA increased from 0.9 LogMAR preoperatively to 0.4 after 1 month (p < 0.00001) and to 0.3 LogMAR after 14 months (p = 0.03). A recovered ELM could be observed in 56.3% after 1 month and in 87.5% after 14 months. A recovered EZ could be observed in 18.8% after 1 month and in 68.8% after 14 months.

CONCLUSION

The study demonstrates a high closure rate with corresponding restitution of outer retinal layers. In addition to its importance for the treatment of MHs > 400 µm, the inverted ILM flap technique also appears to be effective and safe for the treatment of MHs < 400 µm.

TRIAL REGISTRATION

WHO: DRKS00021241.

Effect of inverted internal limiting membrane flap technique on small-medium size macular holes

Inverted internal limiting membrane (ILM) flap technique was developed to achieve macular hole (MH) closure in large MH and refractory cases. In this study, we evaluate the effect of the technique for small-medium size MH. We recruited patients who underwent vitrectomy for small-medium size (< 400 μm) MH with either inverted ILM flap technique (flap group) or with conventional ILM peeling (peeling group). Using propensity score, 21 eyes of 21 patients in the peeling group were matched against 21 eyes of 21 patients in the flap group. We compared MH closure rate, postoperative visual acuity, and recovery of the external limiting membrane (ELM) and ellipsoid zone (EZ). The MH closure rate was not different between the two groups (flap vs peeling: 90% vs 100%, P = 0.49). Whereas there was no significant difference in visual acuity improvement between the two groups, the flap group showed more disruption of the ELM 3 months after surgery and of the EZ at 3 and 6 months after surgery (P = 0.02, P = 0.03, and P = 0.04, respectively). The result suggested that inverted ILM flap technique does not have additional benefits for small-medium size MHs and may delay recovery of retinal integrity.

Update on surgical management of complex macular holes: a review

Modern surgical interventions effectively treat macular holes (MHs) more than 90%. Current surgical treatment for MHs is pars plana vitrectomy with epiretinal membrane, internal limiting membrane (ILM) peeling, gas endotamponade, and prone posturing postoperatively. However, a small subset of MHs imposes challenges to surgeons and frustrations on patients. A narrative review was performed on the surgical treatment of challenging MHs including large and extra-large MHs, myopic MHs with or without retinal detachment, and chronic and refractory MHs. There are robust data supporting inverted ILM flap as the first-line treatment for large idiopathic MHs and certain secondary MHs including myopic MHs. In addition, several studies had shown that ILM flap manipulations in combination with surgical adjuncts increase surgical success, especially in difficult MHs. Even in eyes with limited ILM, surgical options included autologous retinal graft, human amniotic membrane, and creation of a distal ILM flap that can assist in MH closure even though the functional outcome may be affected by the MH chronicity. Despite relative success anatomically and visually after each technique, most techniques require a long-term study to analyze their safety profile and to establish any morphological changes of the MH plug in the closed MHs.

Defining a Cutoff for Progression of Macular Holes

Purpose

The purpose of this study was to determine a cutoff for progression of idiopathic full-thickness macular hole (MH) size.

Methods

Retrospective analysis of consecutive patients waiting 4 weeks for MH surgery. Two observers performed 3 repeat sets of MH size measurements on optical coherence tomography (OCT) high-density radial scans taken at first presentation and 4 weeks later before surgery. Primary outcome was the definition of a cutoff for true enlargement of MH size versus measurement error. Secondary outcomes were risk factors for change in minimum linear diameter (MLD) size and best-corrected visual acuity (BCVA).

Results

Fifty-one patients were included with a mean MH size of 334 µm (±179 µm; range 39 to 793 µm). The cutoff for an increase in MLD size calculated as the outer confidence limit for the 99.73% limits of agreement was 31 µm. This was independent of MH size. Using this cutoff, MLD size increased in 9/34 (26.5%) of patients without and in 14 of 17 (82.4%) of patients with vitreomacular traction (VMT; P < 0.001). Mean BCVA deteriorated in patients in whom the MH had progressed from 0.62 (±0.23) logMAR to 0.82 (±0.29; P < 0.001), whereas there was no significant change in BCVA in patients without MH progression (P = 0.25). In 31% (16/51) of patients, classification of their MHs (small ≤250 µm, medium 251–400 µm, and large >400 µm) changed over the 4-week period.

Conclusions

Using a cutoff discriminates change from measurement error. A significant proportion of MHs progressed by 4 weeks, particularly in the presence of VMT.

Translational Relevance

The established cutoff enables clinicians to differentiate true MH enlargement from measurement error.

Contractility of temporal inverted internal limiting membrane flap after vitrectomy for macular hole

We investigated the postoperative visual outcomes and morphological changes of the internal limiting membrane (ILM) flap, in patients who underwent the temporal inverted ILM flap technique for macular hole (MH). Between August 2018 and February 2020, 22 eyes of 22 patients with idiopathic or myopic MH who underwent vitrectomy with ILM flap were included in this study and followed-up for more than 6 months. Postoperative MH status, comparison of best-corrected visual acuity (BCVA) before and 6 months after surgery, changes in the ILM flap area at 1 and 6 months postoperatively, and the factors related to changes in ILM flap size, were analyzed. MH closure was achieved in all of the patients. The BCVA at 6 months postoperatively (0.18 ± 0.15) was significantly better than the preoperative BCVA of 0.63 ± 0.37 (P < 0.001, paired t test). The area of the ILM flap decreased significantly from 3.25 ± 1.27 mm² at 1 month to 3.13 ± 1.23 mm² at 6 months (P = 0.024, Wilcoxon signed-rank test). Two eyes showed an ILM flap contraction of more than 20%, and one eye required reoperation due to an increase in metamorphopsia and decreased visual acuity. Among age, sex, ILM flap area at 1 month, preoperative BCVA, and axial length, ILM flap contraction was correlated with patient age and ILM flap area. Although vitrectomy with the inverted ILM flap technique confers a good visual outcome, the ILM flap may contract in younger patients.

FUNCTIONAL AND MORPHOLOGICAL OUTCOMES OF THE INVERTED INTERNAL LIMITING MEMBRANE FLAP TECHNIQUE IN SMALL-SIZED AND MEDIUM-SIZED MACULAR HOLES <400 µm

PURPOSE

To assess the effect of an internal limiting membrane flap (IF) in macular hole surgery on the best-corrected visual acuity (BCVA) and integrity of the ellipsoid zone (EZ) and external limiting membrane.

METHODS

Patients were included who had successful surgery for macular hole <400 µm with or without an IF. Main outcome measures were BCVA and restoration of the external limiting membrane and EZ at 12 months.

RESULTS

Sixty patients were included, 36 with conventional peeling and 24 with an IF. The best-corrected visual acuity improved from 0.74 (±0.30) logarithm of the minimum angle of resolution (20/110 Snellen) to 0.26 (±0.20) (20/36 Snellen) in patients without and from 0.77 (±0.32) logarithm of the minimum angle of resolution (20/118 Snellen) to 0.18 (±0.12) (20/30 Snellen) in patients with an IF, respectively. There was no difference in the integrity of the EZ and external limiting membrane in patients with or without an IF at either 3 (P = 0.58, P = 0.20), 6 (P = 0.81, P = 0.10), or 12 months (P = 0.60, P = 0.20) or in the BCVA at 3 (P = 0.24), 6 (P = 0.18) and 12 months (P = 0.11). In the multivariable model, only preoperative BCVA (P < 0.01), EZ integrity (P = 0.001), and age (P < 0.01) were associated with the post-operative BCVA.

CONCLUSION

In patients undergoing surgery for macular hole <400 µm, the use of an IF did not affect the BCVA or the integrity of the EZ and external limiting membrane.

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.

Predictive Association of Pre-Operative Defect Areas in the Outer Retinal Layers With Visual Acuity in Macular Hole Surgery

Purpose

The purpose of this study was to develop methods to model the external limiting membrane (ELM) and ellipsoid zone (EZ) within the elevated cuff surrounding a macular hole (MH) to determine if the predicted size of the defect in these layers after virtual flattening was associated with the actual postoperative defect and best-corrected visual acuity (BCVA).

Methods

Patients were included who had undergone successful MH surgery. The defects in the ELM and EZ after virtual flattening were modeled using in-house software. Main outcomes were postoperative defects in ELM and EZ at 2 months and BCVA at 12 months.

Results

Fifty-eight patients were included. BCVA improved from 0.87 (0.31) logMAR pre-operatively to 0.26 (0.21) at 12 months (P < 0.001). For both the ELM and EZ, the predicted virtually flattened pre-operative defects were associated with the actual postoperative defects at 2 months (R2 = 0.33, P < 0.01 and R2 = 0.50, P < 0.01, respectively). There was a significant association of BCVA at 12 months (adjusted R2 = 0.85) with the pre-operative modeled area of the defect in the ELM (P < 0.01) and to a lesser extent with the defect in the EZ (P < 0.01) and base of the MH (P < 0.01).

Conclusions

Virtually flattening of the pre-operative defect in the ELM provides important predictive information of visual acuity. Incorporation of tools into commercially available optical coherence tomography (OCT) devices to facilitate such measurements would provide the clinician with important prognostic information.

Translational Relevance

We have developed methodology that can potentially be used to predict the postoperative state of the outer retinal layers and the associated visual outcome in patients undergoing surgery for MH.

Anatomical and Functional Outcomes in Eyes with Idiopathic Macular Holes that Underwent Surgery Using the Inverted Internal Limiting Membrane (ILM) Flap Technique Versus the Conventional ILM Peeling Technique

INTRODUCTION

To evaluate the anatomical and functional outcomes of the inverted internal limiting membrane (ILM) flap technique (IFT) in macular holes (MHs), especially in MHs with a macular hole index (MHI) < 0.5.

METHODS

This was a retrospective comparative study. Patients with idiopathic MHs who underwent either the IFT or conventional ILM peeling (CP) were investigated. The main outcomes included the MH closure rate, best corrected visual acuity (BCVA), and recovery rates of the external limiting membrane (ELM) and ellipsoid zone (EZ) at 1, 3, and 6 months postoperatively.

RESULTS

Forty-eight eyes of 48 patients who underwent the IFT (n = 29, Group A) or CP (n = 19, Group B) were included. The mean minimal diameter was 522.00 ± 208.08 µm. The closure rate was 100.0% in Group A and 94.7% in Group B (P = 0.396). The mean BCVA and EZ and ELM recovery rates improved significantly in both groups postoperatively. No significant differences in BCVA or the EZ or ELM recovery rates were found between the two groups. Of the 39 eyes whose MHI was < 0.5, 25 underwent the IFT, and 14 underwent CP. Comparing the results of the closure rate, BCVA and recovery rates of the EZ and ELM between groups were similar to those in 48 eyes.

CONCLUSION

Both the IFT and CP can achieve a high closure rate, with no significant difference in ordinary idiopathic MHs. The IFT does not seem to achieve better anatomical and functional outcomes than CP. The IFT should be used conservatively in ordinary non-refractory MH surgery.

[Large macular hole-Always a poor prognosis?]

Hintergrund

Alter, präoperativer Visus und Makulaforamengröße gelten als prognostische Marker für das postoperative Ergebnis bei Patienten mit durchgreifendem Makulaforamen (MF).

Ziel der Arbeit

Um den postoperativen Verlauf nach i‑ILM Peeling (inverted-Flap ILM-Peeling) mit konventionellem ILM-Peeling (k-ILM) zu vergleichen, wurde eine retrospektive Beobachtungsstudie durchgeführt. Patienten mit i‑ILM Peeling hatten dabei präoperativ ein statistisch signifikant größeres Makulaforamen.

Material und Methoden

Es wurden 45 konsekutive Patienten mit durchgreifendem Makulaforamen (MF) in 2 Gruppen (i-ILM vs. k‑ILM) eingeteilt und auf Unterschiede im postoperativen Visus (BCVA) und der Netzhautmorphologie hin untersucht. Die Integrität der äußeren Netzhautschichten, äußere limitierende Membran (ELM), ellipsoide Zone (EZ) und äußere Photorezeptoraußensegmente (OS), wurde postoperativ mittels SD-OCT (Spectral-Domain-OCT) analysiert.

Ergebnisse

Die präoperative Apertur in der i‑ILM Gruppe war signifikant größer (i-ILM = 408,4 µm, SD = 157,5 µm; k‑ILM = 287,4 µm, SD = 104,9 µm; p = 0,01). Der Ausgangsvisus sowie der postoperative Visus nach 1 Monat waren in der Gruppe mit k‑ILM-Peeling signifikant besser (p = 0,03 und p = 0,001). Der postoperative Visus nach mindestens 6 Monaten zeigte keinen signifikanten Unterschied zwischen den beiden Gruppen (p = 0,24). Die ELM zeigte als erste der äußeren Netzhautschichten eine Re-Integrität in beiden Gruppen.

Schlussfolgerung

Mithilfe der i‑ILM-Peeling-Technik erschien es in dieser konsekutiven Serie möglich zu sein, für Patienten mit großem durchgreifendem MF ein ähnliches postoperatives Visusergebnis zur erreichen wie für mittels k‑ILM-Peeling-Technik operierte Patienten mit kleinerem durchgreifendem MF.

Inverted ILM Flap Technique in Idiopathic Full-Thickness Macular Hole Surgery: Functional Outcomes and Their Correlation with Morphologic Findings

Objectives

The inverted internal limiting membrane (ILM) flap technique has been shown to increase the success rate in large full-thickness macular holes (FTMHs) and in FTMHs associated with high myopia. The aim of our study was to confirm the efficacy and safety of inverted ILM flap technique in idiopathic FTMHs independent of their dimensions and to assess functional outcomes and their correlation to morphologic findings.

Methods

Sixteen consecutive patients affected by idiopathic FTMH were enrolled in this prospective study. The preoperative mean (±SD) diameter of the FTMH was 422 (±106) µm. All patients underwent vitrectomy and ILM peeling with inverted ILM flap. At 1-, 3-, and 6-month postoperative visits, visual acuity measurement, indirect ophthalmoscopy, and microperimetry were performed, and the foveal contour and the integrity of the ellipsoid zone (EZ) and external limiting membrane (ELM) were investigated using spectral domain optical coherence tomography (SD-OCT).

Results

At six months postoperatively, 15 out of 16 (93.75%) patients obtained FTMH closure. The mean best corrected visual acuity (BCVA) improved from 1.1 LogMAR to 0.3 LogMAR, and the mean retinal sensitivity (MS) improved from 7.2 to 23.4 dB. ELM defects were evident in 1 out of 16 (6.25%) eyes, and EZ defects were detected in 2 out of 16 (12,50%) eyes. A statistically significant relationship was observed between BCVA, MS, and EZ reconstitution at each follow-up visit.

Conclusions

Results confirm that the inverted ILM flap technique is a safe and effective option for FTMH treatment and show a strong correlation between higher BCVAs and MSs and EZ reconstitution after surgery.

Inverted internal limiting membrane flap technique in eyes with large idiopathic full-thickness macular hole: long-term functional and morphological outcomes

Purpose

To investigate morphological and functional outcomes of the inverted internal limiting membrane (I-ILM) flap technique in large (≥ 400 μm) idiopathic full-thickness macular holes (FTMH) over a follow-up period of 12 months.

Methods

In this retrospective study, 55 eyes of 54 consecutive patients were enrolled. Best-corrected visual acuity (BCVA) and spectral-domain optical coherence tomography (SD-OCT, Heidelberg, Spectralis) were performed preoperatively as well as 1, 3, 6, 9, and 12 months postoperatively. Special focus was put on the reintegration of outer retinal layers and the different ILM flap appearances.

Results

FTMH closure rate was 100% (55/55). BCVA significantly improved over the follow-up period of 12 months from 0.98 ± 0.38 LogMAR preoperatively to 0.42 ± 0.33 LogMAR at 12 months postoperatively (p < 0.001). There was no significant correlation between the three different ILM flap appearances and BCVA. Better preoperative BCVA, complete restoration of the external limiting membrane (ELM), higher macular hole index (MHI), and smaller MH base diameter were associated with higher improvement of BCVA.

Conclusion

Our study highlights the favorable morphological and functional outcomes of the I-ILM flap technique in the short as well as in the long term. While complete ELM restoration revealed to be an important factor for improvement in BCVA, the different postoperative ILM flap appearances seem not to be related to BCVA.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00417-021-05082-7.

Outcomes of Vitrectomy for Long-Duration Macular Hole

: The present study investigated the functional and anatomical outcomes of idiopathic chronic macular hole (MH) surgery with different surgical approaches related to the chronicity and diameter of the MH. A comparative retrospective study between three groups of patients who underwent vitrectomy for long-duration MH (mean: 13.5 months) was conducted. In the first group of patients (G1 or IP), the internal limiting membrane (ILM) was systematically peeled; in the second group (G2 or IPEP), the ILM and epiretinal membrane (ERM) were peeled; and in the third group (G3 or IF), patients underwent inverted ILM flap technique surgery. Pre- and post-operative best corrected visual acuities (pre- and post-op BCVA) were studied. Macular optical coherence tomography (OCT) scans were performed to measure the MH minimum and maximum diameter pre-operatively, as well as to confirm its post-op closure and evaluate the integrity of the ellipsoid zone (EZ). Fifty eyes of 48 patients (33 female and 15 male) were retrospectively evaluated. MH closure rate was 100% in IP group, 66.7% in IPEP, and 95.2% in IF group. All three groups had a statistically significant improvement of BCVA. EZ post-op was restored in 88.2% of the cases from G1, 41.6% from G2, and 23.8% from G3. No statistically significant relationship between the smaller or larger MH diameter and the visual acuity improvement was found. Patients with chronic MH and ERM have worse functional and anatomical outcomes after surgery. Treatment of chronic MHs without ERM results in a better closure rate with either an inverted ILM flap approach or systematic ILM peel.