Clinical outcomes with large macular holes using the tiled transplantation internal limiting membrane pedicle flap technique

Spotlight on the Internal Limiting Membrane Technique for Macular Holes: Current Perspectives

Pars plana vitrectomy has become the standard procedure for primary macular holes (MHs) repair, including the removal of the posterior cortical vitreous, the stripping of eventual epiretinal membranes, and finally an intraocular gas tamponade. During this procedure, peeling the internal limiting membrane (ILM) has been proven to increase closure rates and avoid postoperative reopening in several researches. In fact, even in large MHs more than 400 µm, the advantage of peeling off the ILM was highlighted by better anatomical closure rates. Nevertheless, some authors suggested that ILM peeling is not always essential, because it generates various side effects in retinal structure and function. Furthermore, the ideal amount of ILM peeling and the most effective strategies for removing the ILM are still subject of research. Different surgical modifications have been reported as alternatives to traditional peeling in certain clinical settings, including ILM flaps, ILM scraping, and foveal sparing ILM peeling. As regards large MHs, the introduction of ILM inverted flap appeared as a game changer, offering a significantly higher >90% closure rate when compared to traditional ILM peeling. Modifications to inverted ILM flap procedures have been claimed in recent years, in order to define the best area and direction of ILM peeling and its correlation with functional outcomes. Moreover, several innovations saw the light in the setting of recurrent MHs, such as ILM free flap transposition, inverted ILM flap combined autologous blood clot technique, neurosensory retinal flap, and human amniotic membrane (HAM) plug, claiming higher anatomical success rate also in those complex settings. In conclusion, the aim of this review is to report how the success rate of contemporary macular surgery has grown since the turn of the century, especially for big and chronic MHs, analyzing in which way ILM management became a crucial point of this kind of surgery.

A Review of Surgical Techniques for the Treatment of Large Idiopathic Macular Holes

BACKGROUND AND OBJECTIVE

This meta-analysis reviews available surgical techniques for the repair of macular holes (MHs) >650 μm.

MATERIAL AND METHODS

PubMed search criteria were used to identify 17 studies outlining surgical techniques for the repair of MHs >650 μm. Thirteen of the studies identified individual cases and were further analyzed based on MH classification. Success was defined as functional improvement and anatomic closure of the hole.

RESULTS

Two hundred and six MHs were included in this study. There were clinically significant differences between the repair of primary and refractory MHs. Autologous retinal transplant resulted in a visual acuity improvement of -0.48 ± 0.36 log-MAR, whereas an inverted internal limiting membrane (ILM) flap and pedicle ILM flap resulted in visual acuity improvements of -0.15 ± 0.17 and -0.14 ± 0.91 logMAR, respectively.

CONCLUSION

An inverted or pedicle ILM flap appears more effective for primary MHs, whereas refractory MHs benefit from a free flap. [Ophthalmic Surg Lasers Imaging Retina. 2022;53:52-61.].

Fluorescence imaging of the ILM flap following MH surgery

Purpose

To report on the imaging of internal limiting membrane (ILM) flap following macular hole (MH) surgery.

Observations

Three eyes of 3 patients with baseline Snellen visual acuities (VAs) of 20/250, 20/30, and 20/100 underwent superior wide-base internal limiting membrane flap transposition (SWIFT) for MH. Indocyanine green (ICG) was used for intraoperative staining of the ILM. Following MH surgery, MH closed in all cases and VAs were 20/30, 20/30, and 20/60 respectively. An “en face” ICG fluorescence image of the ILM flap was obtained using infrared confocal scanning laser imaging at 795 nm. ICG fluorescence demonstrated the ILM flap to be intact and in good position with complete coverage of the MH in all cases. An area of hypofluorescence was present superiorly, corresponding to the flap harvest site with absent ILM. ICG hyperfluorescence of varying intensity was present at the MH site in all 3 cases. Folding of the ILM flap was present in one case.

Conclusions and Importance

Following MH surgery, the status of an ILM flap may be evaluated by an “en face” image of the flap obtained by ICG fluorescence imaging. This imaging modality may be valuable in the study of various ILM flap techniques.

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.

Evaluation of Vision-Related Quality of Life after Autologous Internal Limiting-Membrane Transplantation for Refractory Macular Holes

Purpose

To evaluate the vision-related quality of life of vitrectomy combined with autologous internal limiting membrane (ILM) transplantation for refractory macular holes (MHs).

Methods

There were 40 eyes with refractory MHs included, and all eyes received 23 G vitrectomy and ILM peeling with autologous ILM transplantation. Preoperative and postoperative basic conditions were recorded. The Chinese version of the vision-related quality-of-life scale was used to evaluate patients after operation. Quality of life, postoperative visual acuity, and size of MHs before operation were assessed with Spearman rank correlations.

Results

All patients were followed up for 3 months after surgery. Mean postoperative best-corrected visual acuity had significantly improved after surgery. Vision-related quality of life of patients after surgery was closely related to the MH index, but negatively correlated with best-corrected visual acuity before and after surgery.

Conclusion

The anatomical structure of refractory MHs with ILM peeling combined with autologous ILM transplantation was largely reduced, and the visual acuity of patients improved significantly.