Minimal internal limiting membrane peeling with ILM flap technique for idiopathic macular holes: a preliminary study

Inverted Pedicled Internal Limiting Membrane Flap Attached to an Optic Disc with Autologous Blood Clot for Large Macular Holes

Purpose

An inverted ILM flap might be accidentally separated from the retina or sucked away during surgery for large macular holes (MHs). This article is to determine the efficacy of a new inverted pedicled internal limiting membrane (ILM) flap attached to an optic disc with an autologous blood clot (ABC) technique for the treatment of large MHs.

Methods

An inverted pedicled ILM flap connected to the optic disc with ABC was used to treat 12 consecutive patients with significant macular holes (>600 m). The ILM was first peeled off around MH as a semidiameter of about 1.5 diameters of the optic disc. The superior residual ILM was used to produce a pedicled ILM flap that was connected to the optic disc and was later inverted to cover the MH. The macular hole was covered with a repositioned flap larger than 2 MH diameters in an inverted way. ABC was used to fasten the flap, followed by fluid-air exchange with air or C3F8 as tamponade. Spectral domain-optical coherence tomography (SD-OCT) and best-corrected visual acuity (BCVA) were performed at each postoperative follow-up.

Results

The mean aperture and base macular hole diameters were 737.9 ± 109.6 µm (range, 607-982 µm) and 1244.3 ± 227.4 µm (range, 975-1658 µm). All macular holes (100%) were closed after a single surgery without intraoperative or postoperative complications related to the ILM transposition technique. At the last postoperative visit, we found one eye with a U-shaped closure, three eyes with W-shaped closures, and eight eyes with V-shaped closures. No postoperative flap closures were noted in all cases. The preoperative mean BCVA was 1.5 ± 0.3 (range, 1.1-2.0). After a mean follow-up of 5.3 ± 4.8 (range, 3-16) months, the postoperative mean BCVA was 0.8 ± 0.2 (range, 0.6-1.1), and the difference was statistically significant (p < 0.05).

Conclusion

This novel technique is safe and suitable for large MHs and can be an alternative option for accidental ILM flap loss during other inverted ILM flap operations.

Functional features in patients with idiopathic macular hole treatment via OCT angiography

To evaluate the optical coherence tomography (OCT) angiography features in patients with idiopathic macular hole (IMH) before and after vitrectomy. This prospective study included 25 patients diagnosed with IMH in Shanxi eye hospital from August 2019 to December 2021. The study was divided into 3 groups: IMH eyes, fellow eyes and normal eyes. All unilateral IMH eyes underwent vitrectomy. There were significant differences in superficial retinal blood flow density (SRBFD, P < .001) and choroidal blood flow density (CBFD) between IMH and healthy control eyes before operation (P < .05). There was significant difference in SRBFD between fellow eyes and normal eyes (P = .038). The changes of SRBFD and CBFD in IMH eyes before and after operation were statistically significant (P < .05). The CBFD at 6 months after operation is negatively correlated with LogMAR visual acuity, and the CBFD of the fellow eye is also negatively correlated with LogMAR visual acuity. The SRBFD and CBFD had no correlation with the diameter of macular hole before and after operation. SRBFD and CBFD increased after vitrectomy, indicating that the blood supply of retina and choroid were partially restored after vitrectomy. There was no correlation between SRBFD, CBFD and hole diameter, but there was correlation between choroidal blood flow and LogMAR visual acuity.

Morphological and Functional Features in Patients with Idiopathic Macular Hole Treatment

Purpose

To evaluate the multifocal electroretinogram (mfERG) and optical coherence tomography (OCT) angiography features in patients with idiopathic macular hole (IMH) before and after vitrectomy.

Patients and Methods

This prospective study was conducted at Shanxi Eye Hospital from January 2019 to December 2021. Twenty-five eyes of 25 patients with unilateral IMH, the unaffected fellow eyes, and 30 eyes of healthy patients were investigated. All unilateral IMH eyes underwent vitrectomy.

Results

The IMH eyes had significantly delayed latency (rings 2-5) of mfERG compared with the healthy control eyes, and the amplitude density of all rings of mfERG was reduced (P < 0.05). When comparing the mfERG components before surgery and at the follow-up, the amplitude density of IMH eyes (ring 1, 3, 4 and 5) was increased significantly (P < 0.05). The delayed implicit times of the second and fifth ring were significantly shortened compared with those of preoperative eyes (P < 0.05). The mean delayed implicit time of mfERG in six months after surgery was negatively correlated with visual acuity (r = -0.890, P = 0.043). Significant differences of superficial retinal blood flow density (SRBFD, P < 0.001) and choroidal blood flow density (CBFD) (P < 0.05) got via OCTA were found between IMH before surgery and healthy control eyes. SRBFD of the fellow eyes were significantly different with the healthy control eyes (P = 0.038). Statistically significance of SRBFD and CBFD changes in IMH eyes were found before and after surgery (P < 0.05).

Conclusion

IMH eyes had a decreased amplitude density and a delayed implicit time in some regions. Additionally, SRBFD and CBFD were both increased after vitrectomy, which suggests that the blood supply of the retina and choroid is partially restored after vitrectomy.

Outcomes of Vitrectomy with Fovea-Sparing and Inverted ILM Flap Technique for Myopic Foveoschisis

Surgical treatment of myopic foveoschisis (MF) can result in a macular hole in 11−17% of patients that may lead to poor visual outcomes and progression to macular hole retinal detachment. We evaluated the benefit of vitrectomy to treat MF using the inverted internal limiting membrane (ILM) flap and fovea-sparing ILM techniques. We studied 20 eyes of 20 patients (7 men, 13 women) with high MF (mean axial length, 29.3 ± 1.7 mm). MF was classified by optical coherence tomography findings: retinoschisis (7 eyes) or foveal detachment (13 eyes). Between October 2013 and June 2021, we performed vitreous surgery in all 20 patients, employing both techniques. Air tamponade was used in 4 eyes, SF6 gas in 10 eyes, and C3F8 gas in 6 eyes. All patients stayed in the face-down position for one full day postoperatively. Visual acuity and foveal contour were analyzed using optical coherence tomography before surgery and at 3 and 6 months postoperatively. LogMAR visual acuity was 0.46 before surgery, with a significant improvement at 3 months (0.34) and at 6 months (0.2) postoperatively (p = 0.024, p < 0.001, respectively). In all patients, the foveal contour showed improvement without macular hole formation after surgery. These results show that vitrectomy, performed using the inverted ILM flap and fovea-sparing ILM technique, is effective for treating MF.

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

PURPOSE

This study aims to compare the improvement of best-corrected visual acuity (BCVA) and the reduction in defect length of external limiting membrane (ELM) and ellipsoid zone (EZ) in small ([Formula: see text] 250 μm), medium ([Formula: see text] 250 μm), and large ([Formula: see text] 400 μm) full-thickness macular holes (FTMH) treated with inverted internal limiting membrane (I-ILM) flap technique over a follow-up period of 12 months.

METHODS

Ninety-one eyes of 87 patients were enrolled in this retrospective study. BCVA and spectral-domain optical coherence tomography (SD-OCT) were conducted preoperatively as well as after 1, 3, 6, 9, and 12 months postoperatively. The defect length of the ELM and the EZ was measured using the caliper tool at each follow-up time point.

RESULTS

BCVA improved significantly in the group of small, medium, and large FTMH over the time of 12 months, whereby the improvement did not depend on FTMH size over 9 months. Only after 12 months, large FTMH showed significantly higher BCVA improvement compared to small and medium FTMH. The closure rate was 100% (91/91). The defect length of ELM and EZ reduced continuously over the period of 12 months. There was a significant correlation between defect length of ELM and EZ with postoperative BCVA.

CONCLUSION

The I-ILM flap technique has very good morphological and functional outcomes in small, medium, and large FTMH over a long-time period, indicating that it can be considered as a treatment option in small and medium FTMH. The defect length of ELM and EZ is directly connected to postoperative BCVA.

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.

Factors Associated with Anatomic Failure and Hole Reopening after Macular Hole Surgery

A macular hole (MH), particularly an idiopathic macular hole (IMH), is a common cause of central vision loss. Risk factors for nonidiopathic MH include high myopia, cystoid macular edema, inflammation, and trauma. MH is primarily diagnosed using slit-lamp microscopy and optical coherence tomography (OCT). Half of the patients with stage I MHs are treated conservatively and may show spontaneous resolution. The main treatment methods for MHs currently include vitrectomy and stripping of the internal limiting membrane (ILM). However, in some patients, surgery does not lead to anatomical closure. In this review, we summarize the factors influencing the anatomical closure of MHs and analyze the potential underlying mechanisms.

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.