Comparative Evaluation of Standard ILM Peel With Inverted ILM Flap Technique In Large Macular Holes: A Prospective, Randomized Study

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.

Efficacy of inverted inner limiting membrane flap technique for macular holes of ≤400 μm: A systematic review and meta-analysis

PURPOSE

To evaluate the efficacy of inverted internal limiting membrane (ILM) flap technique in full-thickness macular holes (MHs) with a size of ≤400 μm compared to the ILM peeling technique.

METHODS

Related literatures that compared inverted ILM flap and ILM peeling in MHs ≤ 400 μm were reviewed by searching electronic databases including Pubmed, EMbase, ClinicalTrials.gov, and Cochrane Library up to April 2023. The primary outcome measure was hole closure rate, and the secondary outcome measures were the mean postoperative best-corrected visual acuity (BCVA), retinal sensitivity, and outer status of the retinal layers, including the external limiting membrane and ellipsoid zone. The quality of the articles was assessed according to the revised version of the Cochrane risk-of-bias tool for randomized trials or the Newcastle-Ottawa scale. In the case of heterogeneity, a sensitivity analysis was conducted, and publication bias was visually evaluated using a funnel plot.

RESULTS

This review included six studies with 610 eyes for the primary outcome and 385 eyes for the secondary outcomes, which were two randomized control trials and four retrospective studies. Pooled data revealed that the overall MH closure rate was 99.4% in the inverted ILM flap group and 96.2% in the ILM peeling group, without significant difference between the two groups (odds ratio = 3.91; 95% confidence interval, 0.82~18.69; P = 0.09). The inverted ILM flap technique did not have a favorable effect on the BCVA, retinal sensitivity, or recovery of the outer retinal layers. These results were consistent with those of the subgroup analysis of the different follow-up periods. No significant publication bias was observed.

CONCLUSION

In eyes with MHs of ≤400 μm, both techniques demonstrated excellent surgical outcomes without significant differences. Therefore, surgical techniques can be selected according to surgeon preferences.

Comparison of stereopsis and foveal microstructure after internal limiting membrane peeling and inverted internal limiting membrane flap techniques in patients with macular hole

PURPOSE

To compare stereopsis and foveal microstructure after internal limiting membrane peeling and inverted internal limiting membrane flap technique in patients with macular hole.

DESIGN

Retrospective observational study.

METHODS

Sixty-six patients with macular hole were included, of whom 41 underwent 25-gauge pars-plana vitrectomy with complete internal limiting membrane peeling (Peeling group) and 25 with the inverted flap technique (Inverted group). We evaluated stereopsis using the Titmus Stereo Test and the TNO stereo test, best-corrected visual acuity, macular hole closure rate, and foveal microstructure with optical coherence tomography before and at 3, 6, and 12 months after surgery.

MAIN OUTCOME MEASURES

Stereopsis and foveal microstructure.

RESULTS

Preoperatively, no difference was observed in the base and minimum diameters of macular hole, Titmus Stereo Test score, TNO stereo test score, and best-corrected visual acuity between the Peeling and Inverted groups. The macular hole closure rate in the Peeling and Inverted groups were 97.6% and 100%, respectively, with no significant difference between groups. At 12 months postoperatively, Titmus Stereo Test score (2.1 ± 0.4 in the peeling and 2.2 ± 0.4 in the inverted groups), TNO stereo test score (2.3 ± 0.4 and 2.2± 0.5), and best-corrected visual acuity (0.20 ± 0.18 and 0.24 ± 0.25) were not significantly different between groups (p = 0.596, 0.332, respectively). The defect of the external limiting membrane was more common in the Inverted group than in the Peeling group at 6 months after surgery (5.4 vs. 28.0%; p < 0.05). No statistically significant inter-group differences were noted in the ellipsoid zone defect ratio throughout the follow-up period.

CONCLUSIONS

There was no difference in postoperative stereopsis nor foveal microstructure between the internal limiting membrane peeling group and the inverted group in patients with macular hole.

Closure rate and recovery of subfoveal microstructures following conventional internal limiting membrane peeling versus per fluoro octane-assisted inverted flap for large macular holes - A randomized controlled trial (InFlap Study)

PURPOSE

To analyze the outcomes following conventional internal limiting membrane (ILM) peeling versus perfluoro octane-assisted inverted flap technique for large macular holes (MH).

METHODS

A consecutive 99 eyes of 99 patients were enrolled {45 - conventional group and 54 - inverted flap (InFlap) group}. The primary outcome was a difference in closure rate. Secondary outcomes were differences in best-corrected visual acuity (BCVA), restoration of external limiting membrane (ELM) and ellipsoid zone (EZ) between groups at 3 (primary endpoint), 6 and 12 (secondary endpoints) months. Additionally, the effect of different gas tamponades on closure rates, ILM flap disintegration in InFlap group, and subfoveal thickness (SFT) between groups in closed.

RESULTS

At 3 months, there was no difference in the closure rate and BCVA between groups. At six months, closure rate was significantly better in the InFlap group. However, this difference was not maintained at 12 months. There was no difference in BCVA between groups at any visit. The ELM recovery was significantly higher in the conventional group at three months; however, there was no difference in ELM/EZ recovery between groups at other visits. The closure rate in the InFlap group was the same irrespective of gas tamponade. The ILM flap was identifiable in one-third of patients at 12 months. In closed MH, SFT was significantly more in InFlap group.

CONCLUSION

The closure rate and visual outcomes remained similar in both groups in the immediate and long term. Conventional ILM peeling technique seems to have early ELM recovery when compared to inverted flap technique.

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.

Repeat Surgery following Temporal Inverted ILM Flap Technique: Next Step after Primary Failure

PURPOSE

We aimed to report our surgical experience with repeat surgery as the next step after an unsuccessful hole closure with the primary single-layered temporal inverted flap technique (IFT).

METHODS

We identified cases with persistent macular holes by reviewing the records of eyes that underwent IFT between October 2018 and October 2021. These cases were evaluated for hole features, anatomical closure, and visual improvement before and after the first and second surgeries. In addition, the technique applied in repeat surgery was recorded. Optical coherence tomography (OCT) images at follow-up were used to evaluate the flap position.

RESULTS

A persistent hole was identified in 11 (6.4%) of 172 patients who underwent IFT. An inferotemporal displacement was observed in seven eyes, while no flap could be identified in the OCT images of the other four eyes. In the second surgery, the old flap was reinverted in one eye, and a new flap was created from the superior region in five eyes and the nasal region in the other five eyes and was stabilized under perfluorocarbon liquid. A gas tamponade (C3F8/SF6) was used in all patients at the end of surgery. The minimum hole diameter was > 400 µm in all eyes and 100% closure was achieved after the second surgery. Visual acuity gain of ≥ 3 lines was observed in 9 of the 11 eyes (81.8%). The mean visual acuity increase at the last follow-up was significant (p = 0.008).

CONCLUSION

With single-layer temporal IFT in the primary surgery of macular holes, unsuccessful results may be observed due to the flap displacement in the early period. In our series, IFT was applied again with the use of the old flap or the creation of a new flap in the second surgery of the persistent holes, and successful results were obtained.

Modification of the inverted flap technique compared to conventional internal limiting membrane peeling in complete macular hole surgery

AIM

To describe the efficacy of a modification of the superior inverted flap technique, with maculorrhexis, in vitrectomy for full-thickness macular hole (MH) surgery compared to internal limiting membrane peeling (ILM).

METHODS

Retrospective and comparative study of patients with MH. In group A, a superior ILM flap is created to cover the macular hole, and in group B conventional ILM peeling was performed.

RESULTS

A total of 80 eyes were included (44 group A and 36 group B). MH closure occurred in 100% in group A and 91.67% in group B (p = 0.0869). There were more U-type closures in group A(90.91%) than in group B(58.33%), p = 0.0017. Both groups showed Best corrected visual acuity (BCVA) improvement at 3 and 6 months. At 3 months BCVA in group A was significantly better but at 6 months results were similar. Ellipsoid layer (EZ) recovery at 6 months was achieved in 81.82% patients in group A and 52.78% in B (p = 0.005), and external limiting membrane in 81.82% in group A and 69.44% in B (p = 0.1957).

CONCLUSIONS

The superior inverted flap maculorrhexis technique is suitable for idiopathic MH treatment, with better anatomical and non-inferior functional results than the classic ILM peeling. It achieves functional recoveries earlier, better BCVA and greater gains at 3 months compared to the classic ILM peeling. It also obtains a higher number of U-shaped closures and higher EZ restorations.

Single Layered Free ILM Graft Technique in Large Macular Holes with Associated ERM

PURPOSE

We aimed to describe single layered free ILM graft technique (FIGT) and present results of this technique in the primary surgery of large macular holes (MHs).

METHODS

In this retrospective study, we identified MHs with a minimum hole diameter >400 μm that underwent FIGT by a single surgeon. Nineteen eyes were found to have an associated epiretinal membrane (ERM) and four eyes demonstrated a patchy ILM staining intraoperatively. A single layered FIGT was performed first by peeling the ILM around the hole and then creating a free ILM flap and transplanting it to cover the hole. All cases were evaluated for anatomical closure and visual improvement.

RESULTS

Twenty-three eyes of 22 patients (mean age 68.7 ± 7.4 years) were included in the study. The mean follow-up was 9.6 ± 4.9 months. Flap closure was observed in two eyes (8.6%) at week 1, while all eyes (100%) showed a complete closure at month 1. Mean preoperative visual acuity of 1.42 ± 0.66 LogMAR increased to 1.11 ± 0.51, 0.99 ± 0.34, 0.92 ± 0.38, 0.74 ± 0.37, 0.52 ± 0.28, 0.64 ± 0.39 respectively at week 1, month 1, month 3, month 6, year 1 and final follow-up postoperatively (p < .05 for all). In none of the eyes ERM recurred, nor flap contraction developed.

CONCLUSION

The study showed encouraging results using free ILM graft in the primary surgery of large MHs. This technique might be considered in large MHs that are associated with ERM or demonstrate patchy ILM staining. Further studies are needed to prove the effectiveness also in the long-term.

Inverted Internal Limiting Membrane Flap versus Internal Limiting Membrane Insertion Technique for Large Macular Holes: A Meta-Analysis

PURPOSES

This meta-analysis aimed to compare and evaluate the morphological and functional outcomes between the inverted internal limiting membrane (ILM) flap and ILM insertion techniques in the treatment of large macular holes (MHs).

METHODS

The PubMed, Embase, and Cochrane Library databases were searched for relevant studies comparing the two techniques for the treatment of large MHs. The primary outcome measures included the MH closure rate, preoperative and postoperative best-corrected visual acuity (BCVA), MH closure patterns, and external limiting membrane (ELM) and ellipsoid zone (EZ) recovery. Statistical analyses were performed using RevMan 5.3 software.

RESULTS

Two randomized controlled trials and four retrospective studies were included in this meta-analysis. The MH closure rate did not significantly differ between the two groups (P = .93). Postoperative BCVA was not significantly different between the two groups at 3 months (P = .20) or 6 months (P = .51). ELM and EZ recovery were also similar between the two groups. However, the results for postoperative BCVA and outer retinal structure recovery tended to favor the ILM flap group based on the forest plot. There was no significant difference between the two groups for the U-shape (P = .26), V-shape (P = .65), and W-shape closure types (P = .38).

CONCLUSIONS

Our meta-analysis provides evidence that the MH closure rate and visual function outcomes are similar between the ILM flap and ILM insertion techniques in large MHs. However, based on the forest plot, postoperative BCVA and outer retinal layer reconstruction tended to favor the ILM flap technique. Further studies with larger sample sizes are required to confirm the superiority of the ILM flap to the ILM insertion technique.

Pars plana vitrectomy with internal limiting membrane flap versus pars plana vitrectomy with conventional internal limiting membrane peeling for large macular hole

BACKGROUND

Macular hole (MH) is a full-thickness defect in the central portion of the retina that causes loss of central vision. According to the usual definition, a large MH has a diameter greater than 400 µm at the narrowest point. For closure of MH, there is evidence that pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling achieves better anatomical outcomes than standard PPV. PPV with ILM peeling is currently the standard of care for MH management; however, the failure rate of this technique is higher for large MHs than for smaller MHs. Some studies have shown that the inverted ILM flap technique is superior to conventional ILM peeling for the management of large MHs.

OBJECTIVES

To evaluate the clinical effectiveness and safety of pars plana vitrectomy with the inverted internal limiting membrane flap technique versus pars plana vitrectomy with conventional internal limiting membrane peeling for treating large macular holes, including idiopathic, traumatic, and myopic macular holes.

SEARCH METHODS

The Cochrane Eyes and Vision Information Specialist searched CENTRAL, MEDLINE, Embase, two other databases, and two trials registries on 12 December 2022.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) that evaluated PPV with ILM peeling versus PPV with inverted ILM flap for treatment of large MHs (with a basal diameter greater than 400 µm at the narrowest point measured by optical coherence tomography) of any type (idiopathic, traumatic, or myopic).

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane and assessed the certainty of the body of evidence using GRADE.

MAIN RESULTS

We included four RCTs (285 eyes of 275 participants; range per study 24 to 91 eyes). Most participants were women (63%), and of older age (range of means 59.4 to 66 years). Three RCTs were single-center trials, and the same surgeon performed all surgeries in two RCTs (the third single-center RCT did not report the number of surgeons). One RCT was a multicenter trial (three sites), and four surgeons performed all surgeries. Two RCTs took place in India, one in Poland, and one in Mexico. Maximum follow-up ranged from three months (2 RCTs) to 12 months (1 RCT). No RCTs reported conflicts of interest or disclosed financial support. All four RCTs enrolled people with large idiopathic MHs and compared conventional PPV with ILM peeling versus PPV with inverted ILM flap techniques. Variations in technique across the four RCTs were minimal. There was some heterogeneity in interventions: in two RCTs, all participants underwent combined cataract-PPV surgery, whereas in one RCT, some participants underwent cataract surgery after PPV (the fourth RCT did not mention cataract surgery). The critical outcomes for this review were mean best-corrected visual acuity (BCVA) and MH closure rates. All four RCTs provided data for meta-analyses of both critical outcomes. We assessed the risk of bias for both outcomes using the Cochrane risk of bias tool (RoB 2); there were some concerns for risk of bias associated with lack of masking of outcome assessors and selective reporting of outcomes in all RCTs. All RCTs reported postoperative BCVA values; only one RCT reported the change in BCVA from baseline. Based on evidence from the four RCTs, it is unclear if the inverted ILM flap technique compared with ILM peeling reduces (improves) postoperative BCVA measured on a logarithm of the minimum angle of resolution (logMAR) chart at one month (mean difference [MD] -0.08 logMAR, 95% confidence interval [CI] -0.20 to 0.05; P = 0.23, I2 = 65%; 4 studies, 254 eyes; very low-certainty evidence), but it may improve BCVA at three months or more (MD -0.17 logMAR, 95% CI -0.23 to -0.10; P < 0.001, I2 = 0%; 4 studies, 276 eyes; low-certainty evidence). PPV with an inverted ILM flap compared to PPV with ILM peeling probably increases the proportion of eyes achieving MH closure (risk ratio [RR] 1.10, 95% CI 1.02 to 1.18; P = 0.01, I2 = 0%; 4 studies, 276 eyes; moderate-certainty evidence) and type 1 MH closure (RR 1.31, 95% CI 1.03 to 1.66; P = 0.03, I² = 69%; 4 studies, 276 eyes; moderate-certainty evidence). One study reported that none of the 38 participants experienced postoperative retinal detachment.

AUTHORS' CONCLUSIONS

We found low-certainty evidence from four small RCTs that PPV with the inverted ILM flap technique is superior to PPV with ILM peeling with respect to BCVA gains at three or more months after surgery. We also found moderate-certainty evidence that the inverted ILM flap technique achieves more overall and type 1 MH closures. There is a need for high-quality multicenter RCTs to ascertain whether the inverted ILM flap technique is superior to ILM peeling with regard to anatomical and functional outcomes. Investigators should use the standard logMAR charts when measuring BCVA to facilitate comparison across trials.

The Effect of Macular Hole Duration on Surgical Outcomes: An Individual Participant Data Study of Randomized Controlled Trials

TOPIC

To define the effect of symptom duration on outcomes in people undergoing surgery for idiopathic full-thickness macular holes (iFTMHs) by means of an individual participant data (IPD) study of randomized controlled trials (RCTs). The outcomes assessed were primary iFTMH closure and postoperative best-corrected visual acuity (BCVA).

CLINICAL RELEVANCE

Idiopathic full-thickness macular holes are visually disabling with a prevalence of up to 0.5%. Untreated BCVA is typically reduced to 20/200. Surgery can close holes and improve vision. Symptom duration is thought to affect outcomes with surgery, but the effect is unclear.

METHODS

A systematic review identified eligible RCTs that included adults with iFTMH undergoing vitrectomy with gas tamponade in which symptom duration, primary iFTMH closure, and postoperative BCVA were recorded. Bibliographic databases were searched for articles published between 2000 and 2020. Individual participant data were requested from eligible studies.

RESULTS

Twenty eligible RCTs were identified. Data were requested from all studies and obtained from 12, representing 940 eyes in total. Median symptom duration was 6 months (interquartile range, 3-10). Primary closure was achieved in 81.5% of eyes. There was a linear relationship between predicted probability of closure and symptom duration. Multilevel logistic regression showed each additional month of duration was associated with 0.965 times lower odds of closure (95% confidence interval [CI], 0.935-0.996, P = 0.026). Internal limiting membrane (ILM) peeling, ILM flap use, better preoperative BCVA, face-down positioning, and smaller iFTMH size were associated with increased odds of primary closure. Median postoperative BCVA in eyes achieving primary closure was 0.48 logarithm of the minimum angle of resolution (logMAR) (20/60). Multilevel logistic regression showed for eyes achieving primary iFTMH closure, each additional month of symptom duration was associated with worsening BCVA by 0.008 logMAR units (95% CI, 0.005-0.011, P < 0.001) (i.e., ∼1 Early Treatment Diabetic Retinopathy Study letter loss per 2 months). ILM flaps, intraocular tamponade using long-acting gas, better preoperative BCVA, smaller iFTMH size, and phakic status were also associated with improved postoperative BCVA.

CONCLUSIONS

Symptom duration was independently associated with both anatomic and visual outcomes in persons undergoing surgery for iFTMH. Time to surgery should be minimized and care pathways designed to enable this.

CONVENTIONAL INTERNAL LIMITING MEMBRANE PEELING VERSUS INVERTED FLAP FOR SMALL-TO-MEDIUM IDIOPATHIC MACULAR HOLE: A Randomized Trial

PURPOSE

To compare conventional internal limiting membrane (ILM) peeling versus inverted flap technique in small-to-medium idiopathic macular hole.

METHODS

Eyes with ≤400 μ m idiopathic macular holes were randomized into the conventional ILM peeling group (25 eyes) and inverted flap group (25 eyes). A 12-month follow-up was considered. Macular sensitivity (MS) change detected with MP-1 microperimetry was the primary outcome. Secondary outcomes included best-corrected visual acuity change, closure rate, anatomical findings on optical coherence tomography such as U-shape foveal contour, restoration of external limiting membrane, and ellipsoid zone.

RESULTS

In both groups, MS improved throughout the follow-up. Final MS was greater in the conventional ILM peeling group compared with the inverted flap group, being 16.6 ± 2.3 dB versus 14.9 ± 2.9 dB, respectively ( P = 0.026). In both groups best-corrected visual acuity improved throughout the follow-up, with a final best-corrected visual acuity of 0.19 ± 0.14 logMar (20/31 Snellen) in the conventional ILM group and 0.22 ± 0.11 logMar (20/33 Snellen) in the inverted flap group ( P = 0.398). Anatomical hole closure was achieved in all cases. No difference in optical coherence tomography findings was shown between the two groups.

CONCLUSION

A better final MS was found in eyes undergoing conventional ILM peeling. Inverted flap technique has disadvantages compared with conventional peeling for the treatment of small-to-medium idiopathic macular holes.

Modified inverted internal limiting membrane flap technique for macular hole closure

PURPOSE

To investigate the efficacy of modified internal limiting membrane (ILM) flap technique combined with vitreous surgery for treating macular holes and examine the outcomes in visual function and anatomic macular hole closure.

STUDY DESIGN

Retrospective, observational.

METHODS

Between July 1, 2015, and October 1, 2019, the modified inverted ILM flap technique combined with vitreous surgery was used to treat idiopathic macular holes, postoperative progression was then followed for at least 6 months in 96 participants (98 eyes). We modified the method by removing the lower half of the ILM while peeling and inverting the upper half. The mean age of the participants was 65.9 ± 11.9 years (41 men (42.7%) and 55 women (57.3%)). Retrospective evaluations of macular hole diameter, corrected visual acuity, and macular hole closure rates were performed using data from medical records.

RESULTS

The mean macular hole diameter was 623.6 ± 207.4 μm. The mean corrected visual acuity (logMAR) was 0.79 ± 0.27 before surgery and 0.46 ± 0.35 at 1, 0.35 ± 0.39 at 3, and 0.31 ± 0.36 at 6 months Post surgery, showing significant differences before and after surgery (p = 2.30 × 10^- 2). The macular hole closure rate was 98%.

CONCLUSION

The modified inverted ILM flap technique combined with vitreous surgery was an effective method for treating macular holes, resulting in improvement in closure and visual acuity.

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.

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.

Surgical Management of Recurrent and Persistent Macular Holes: A Practical Approach

Primary surgery for macular hole (MH) closure has a high success rate with current methods of pars plana vitrectomy and internal limiting membrane (ILM) peeling. When primary surgery fails, there are several options available for secondary repair, including extension of the ILM peel, creation of an ILM flap, pedunculated ILM flap, lens capsule flap transplantation, autologous retinal transplantation, use of a human amniotic membrane plug, adjuvant autologous platelet concentrate, induction of macular detachments with subretinal blebs, and creation of retinal incisions. In this review, we discuss the practical approach to each of these surgical techniques for the management of recurrent or persistent MHs.

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.

Comparison of platelet-rich plasma and inverted internal limiting membrane flap for the management of large macular holes: A pilot study

Purpose:

To compare the safety and efficacy of 25-gauge pars plana vitrectomy (PPV) with either platelet-rich plasma (PRP) or inverted internal limiting membrane (ILM) flap for the treatment of large macular hole.

Methods:

Pseudophakic patients with idiopathic macular holes with a minimum diameter (MD) of 600–1500 μm were randomized into two groups (30 patients each): 25-gauge PPV with either inverted ILM flap (group A) or PRP (group B).

Results:

Mean MD in groups A and B were 803.33 ± 120.65 μm and 784.73 ± 120.10 μm, respectively (P = 0.552). Mean base diameter in groups A and B was 1395.17 ± 240.57 μm and 1486.90 ± 281.61 μm, respectively (P = 0.180). The median presenting best-corrected visual acuity (BCVA) was logMAR 0.78 (range 0.78–1.00) and logMAR 0.78 (Range 0.60–1.00) in groups A and B, respectively (P = 0.103). Anatomical closure was achieved in 90% (n = 27/30) and 93.3% (n = 28/30) eyes in groups A and B, respectively (P = 0.158). Type 1 closure was achieved in 76.7% (n = 23/30) and 83.3% (n = 25/30) eyes in groups A and B, respectively. Median BCVA at postoperative 3-month in groups A and B was logMAR 0.60 (range 0.48–0.60) and logMAR 0.60 (range 0.48–0.78), respectively (P = 0.312). The average visual improvement was 2.0 and 2.5 early treatment diabetic retinopathy study (ETDRS) lines in groups A and B, respectively (P = 0.339). None of the patients developed postoperative exaggerated inflammatory reactions.

Conclusion:

Using platelets for the treatment of large macular holes is as safe and effective as an inverted ILM flap.

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.

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.

Inverted internal limiting membrane flap technique versus internal limiting membrane peeling for large macular holes: A meta-analysis of randomized controlled trials

BACKGROUND

Vitrectomy with internal limiting membrane (ILM) peeling is an effective surgical procedure for the treatment of macular holes (MHs). However, there is a possibility of poor postoperative anatomical closure with conventional ILM peeling for MHs larger than 400 μm. Therefore, a novel inverted ILM flap technique was developed for such cases.

OBJECTIVES

This meta-analysis study was performed to evaluate and compare the anatomical and visual outcomes of the inverted ILM flap technique and ILM peeling in large MHs.

METHODS

The Cochrane Library, PubMed, and Embase databases were searched to identify randomized controlled trials (RCTs). The trial eligibility and risk of bias were assessed according to Cochrane review methods. The primary outcome measures included MH closure rate and postoperative visual acuity (VA). Subgroup analysis of postoperative VA based on follow-up time was also conducted. Pooled odds ratios (ORs), weighted mean difference (WMD), and 95% confidence intervals (CIs) were calculated. Statistical analysis was performed using RevMan 5.3 software.

RESULTS

Five RCTs with a total of 155 eyes in the inverted ILM flap group and 161 eyes in the ILM peeling group were included in this meta-analysis. Statistical meta-analysis revealed that the overall MH closure rate in the inverted ILM flap group was significantly higher than that in the ILM peeling group (OR, 3.10; 95% CI, 1.25 to 7.66; P = 0.01). The postoperative VA was significantly better in the inverted ILM flap group than ILM peeling group (WMD, -0.14; 95% CI, -0.21 to -0.07; P = 0.0002). The subgroup meta-analysis indicated that the postoperative VA was significantly better in the inverted ILM flap group than ILM peeling group (WMD, -0.17; 95% CI, -0.26 to -0.08; P = 0.0004) at the 3-month follow-up. However, no significant difference was observed between the two groups at the 6-month follow-up (WMD, -0.09; 95% CI, -0.20 to 0.02; P = 0.10).

CONCLUSIONS

Vitrectomy with inverted ILM flap technique showed a higher anatomical closure rate as well as visual gain-although only in the short-term as no difference in visual recovery was found at the 6-month follow-up-than did ILM peeling in large MHs. The inverted ILM flap technique should be considered as a preferred and routine procedure for the treatment of patients with MHs larger than 400 µm.

A novel video overlay guided enlargement of area of ILM peeled versus inverted flap technique: A long-term study in large macular holes

BACKGROUND/AIM

To compare the intra-operative video overlay guided enlargement of Area of ILM peeled (AIP) more than three Disc Diameter (DD) versus the inverted flap technique in large (>400 µm ) Full Thickness Macular Holes (FTMH).

METHODS

Retrospectively, 127 cases of large FTMHs divided into two groups (i) Group A (n = 62)-intra-operative video-overlay guided enlargement of AIP > 3DD performed and (ii) Group B (n = 65)-Inverted flap technique was done. Mean Best Corrected Visual Acuity (BCVA), hole closure rate and postoperative foveal anatomy were noted on Optical Coherence Tomography (OCT).

RESULTS

Mean Minimal Diameter of Macular Hole (MDMH) were 632.05 ± 146.62 µm (A) and 677.24 ± 152.08 µm (B). Hole closure rate were 93.55% (A) and 96.92% (B). Mean preoperative BCVA was 1.07 ± 0.37 Log MAR (A) and 0.94 ± 0.23 Log MAR (B). Mean postoperative BCVA at 3 months were 0.73 ± 0.22 Log MAR (A) and 0.83 ± 0.24 Log MAR (B). One-way ANOVA test showed statistically better visual improvement in Group A at 3 months (p = 0.02), 6 months (p = 0.045), 12 months (p = 0.002), and 24 months (p = 0.011). Chi square test revealed Type I pattern of hole closure was statistically more in Group B (p < 0.001). Delayed Recovery of Outer Retinal Layers was more in group B (Pearson Chi square test, p = 0.039).

CONCLUSION

Anatomically, macular hole closure rate as well as closure pattern was better in Group B. But functional improvement was better in Group A.

Inverted ILM flap technique versus conventional ILM peeling for idiopathic large macular holes: A meta-analysis of randomized controlled trials

Purpose

To compare the anatomical and visual outcomes of inverted internal limiting membrane (ILM) flap technique with the conventional ILM peeling for idiopathic large macular holes (MHs).

Methods

A meta-analysis of randomized control trials (RCTs) using online databases including NCBI PubMed, ClinicalTrials.gov, and ISI Web of Science was performed. Anatomic success and type 1 closure rates, the mean postoperative best-corrected visual acuity (BCVA) and the mean change of BCVA from baseline were analyzed.

Results

Out of 251 articles, four described clinical trials matching the inclusion criteria and were selected. They included 276 eyes (135 eyes in the inverted ILM flap group and 141 eyes in the ILM peeling group). All the studies used gas tamponade, with two studies having a follow-up duration of 3 months, while one study had a follow-up of 6 months and one study– 12 months. The meta-analysis demonstrated that anatomic success and type 1 closure rates (presence of neurosensory retina in MH) were better in the inverted ILM flap technique (odds ratio (OR) = 4.89; 95% confidence interval (CI), 2.09–11.47; P = 0.0003 and OR = 5.23; 95% CI, 2.83–9.66; P<0.00001). Similarly, the inverted flap technique was superior in terms of postoperative logMAR BCVA and mean change of logMAR BCVA from baseline (weighted mean difference (WMD) = 0.17, 95% CI, 0.11 to 0.24, P<0.00001 and WMD = 0.08, 95% CI, 0.01 to 0.16, P = 0.03)

Conclusion

Inverted ILM flap treatment resulted in better closure rates and visual acuity when compared to the standard ILM peeling for large MHs.

Inverted temporal internal limiting membrane flap technique for chronic large traumatic macular hole

Various modifications of surgical techniques and surgical adjuncts are adopted with standard pars plana vitrectomy (PPV) to improve the outcome of traumatic macular hole (TMH) surgeries. We describe a successful closure of a chronic large TMH of three years duration with inverted temporal internal limiting membrane (ILM) flap technique. A 36-year-old male patient had an optical coherence tomography (OCT) documented chronic macular hole (MH) for three years following blunt trauma. Fundus examination also showed choroidal rupture scar temporal to fovea. The minimum MH diameter was 769 µ and the basal diameter 1431 µ in OCT. Standard PPV with inverted temporal ILM flap and gas tamponade was done. The postoperative period was uneventful. The best corrected visual acuity improved from 6/60 preoperatively to 6/18 six months postoperatively, and OCT showed a closed MH with anatomical type 1 closure. This case highlights that the inverted temporal ILM flap technique is a safe and effective technique for patients with even chronic and large TMH.

Perfluorocarbon liquid-assisted inverted inner limiting membrane-flap for large macular hole after recurrent rhegmatogenous retinal detachment

A 45-year-old Caucasian myopic woman with a severe vision impairment (20/320) in the left eye due to a macula-off rhegmatogenous retinal detachment (RRD) underwent vitrectomy with silicone oil tamponade followed by an inferior relaxing retinectomy with heavy silicone oil tamponade during the second procedure for recurrence of RRD due to proliferative vitreoretinopathy. Four weeks after the second surgery, visual acuity was 20/200 and the patient complained metamorphopsia in the same eye due to a large full-thickness macular hole. A perfluorocarbon liquid-assisted inverted inner limiting membrane-flap technique was performed. Visual acuity improved to 20/80 after closing of macular hole and partial recovery of outer retinal layers at 3 months from the last surgery.

Internal limiting membrane dragging and peeling: a modified technique for macular holes closure surgery

AIM

To introduce a modified technique of internal limiting membrane (ILM) centripetal dragging and peeling to treat idiopathic macular hole (IMH) and to observe the ILM-retina adhesive forces.

METHODS

Twenty-six consecutive patients with stage 3 to 4 IMH and followed up at least six months were enrolled. All patients underwent complete par plana vitrectomy, ILM dragging and peeling, fluid and gas exchange, 15% C₃F₈ tamponade and 2-week prone position. The best corrected visual acuity, macular hole evaluation by optical coherence tomography, and complications were evaluated.

RESULTS

The mean diameter of IMH was 524±148 µm (range: 201-683 µm), with 21 cases (80.8%) greater than 400 µm. ILM dragging and peeling were successfully performed in all cases. Most of the ILM-retina adhesive forces are severe (42.3%, 11/26), followed by mild (38.5%, 10/26), and moderate (19.2%, 5/26). The mean follow-up duration was 21.2±6.1mo. The IMH was closed in 25 (96.3%) eyes. Visual acuity (logMAR) improved significantly from 1.2±0.6 preoperatively to 0.7±0.5 postoperatively (P<0.001).

CONCLUSION

Preexisting ILM-retina adhesive force is found in IMH patients. With assistance of this force, this modified technique may help to release the IMH edges and improve the closure rate of large IMH.

Microperimetric Biofeedback Training after Successful Inverted Flap Technique for Large Macular Hole

Background: Despite the high closure rate of large macular hole (LMH) after surgery, visual recovery is often worse than expected. Microperimetric biofeedback can improve visual function in macular pathologies. We evaluated the efficacy of biofeedback on macular function after successful inverted flap technique for LMH. Methods: In this prospective comparative study, 26 patients after LMH surgical closure were enrolled. The whole sample was equally divided into two groups. In Group 1 (trained), patients underwent a double cycle of microperimetric biofeedback, using structured light stimulus plus acoustic tone; in Group 2 (control), patients underwent scheduled visits. We analyzed visual acuity, retinal sensitivity at central 12° (macular sensitivity, MS) and 4° (central macular sensitivity, CMS), and fixation stability over twelve months. Results: Visual acuity improved mainly in the trained group, without any significant differences between the groups (p > 0.05). Only after training did MS significantly improve (p = 0.01). CMS more significantly improved in the trained (p < 0.001) than the control group (p < 0.01) (Group 1 vs. 2, p = 0.004). Only in the trained group did fixation significantly improve (3 months, p ≤ 0.03; 12 months, p ≤ 0.01). An equality test on matched data confirmed a greater significant improvement of CMS (p ≤ 0.02) at all follow-up and fixation (p ≤ 0.02) at last follow-up after training. Conclusions: Microperimetric biofeedback consolidates and increases the improvement of retinal sensitivity and fixation gained after successful inverted flap technique.

Comparative efficacy evaluation of inverted internal limiting membrane flap technique and internal limiting membrane peeling in large macular holes: a systematic review and meta-analysis

Background

The purpose of this study was to compare the anatomical and visual outcomes of inverted internal limiting membrane (ILM) flap technique and internal limiting membrane peeling in large macular holes (MH).

Methods

Related studies were reviewed by searching electronic databases of Pubmed, Embase, Cochrane Library. We searched for articles that compared inverted ILM flap technique with ILM peeling for large MH (> 400 μm). Double-arm meta-analysis was performed for the primary end point that was the rate of MH closure, and the secondary end point was postoperative visual acuity (VA). Heterogeneity, publication bias, sensitivity analysis and subgroup analysis were conducted to guarantee the statistical power.

Results

This review included eight studies involving 593 eyes, 4 randomized control trials and 4 retrospective studies. After sensitivity analysis for eliminating the heterogeneity of primary outcome, the pooled data showed the rate of MH closure with inverted ILM flap technique group was statistically significantly higher than ILM peeling group (odds ratio (OR) = 3.95, 95% confidence interval (CI) = 1.89 to 8.27; P = 0.0003). At the follow-up duration of 3 months, postoperative VA was significantly better in the group of inverted ILM flap than ILM peeling (mean difference (MD) = − 0.16, 95% CI = − 0.23 to 0.09; P < 0.00001). However, there was no difference in visual outcomes between the two groups of different surgical treatments at relatively long-term follow-up over 6 months (MD = 0.01, 95% CI = − 0.12 to 0.15; P = 0.86).

Conclusion

Vitrectomy with inverted ILM flap technique had a better anatomical outcome than ILM peeling. Flap technique also had a signifcant visual gain in the short term, but the limitations in visual recovery at a longer follow-up was found.

Inverted internal limiting membrane-flap technique for large macular hole: a microperimetric study

Background

Inverted Internal Limiting Membrane (ILM)-flap technique would seem to lead to higher closure rate and better visual acuity than traditional procedure with ILM peeling for the treatment of large macular hole (LMH). Visual acuity recovery does not reveal many other functional changes related to surgical approach. Our purpose was to evaluate macular function and morphology over a 1-year follow-up after inverted ILM-flap technique for LMH by using microperimetry in order to predict visual prognosis.

Methods

This study was a prospective unrandomized single-center study. 23 eyes of 22 patients with idiopathic LMH, with a minimum diameter ranging from 400 to 1000 μm, were included. All patients underwent vitrectomy with inverted ILM-flap technique and gas tamponade. We analyzed macular hole closure rate and functional outcomes including best-corrected visual acuity (BCVA), macular sensitivity (MS) at central 12° and central macular sensitivity (CMS) at central 4°, and fixation behavior as bivariate contour ellipse area (BCEA, degrees²) at 68%, 95%, and 99% of fixation points measured by microperimeter, over a follow-up of 12 months.

Results

The macular hole closure rate was 98%. The BCVA improved from 20/230 (Logmar, 1.06 ± 0.34) to 20/59 (logMar, 0.47 ± 0.45) at last follow-up (p < 0.001). Retinal sensitivity and BCEA significantly improved (MS, p = 0.001; CMS, p < 0.0001; BCEA: 68%, p < 0.01; 95%, p < 0.01; 99%, p = 0.001). Multiple stepwise regression analysis showed the final BCVA was significantly associated with macular hole size (β = 0.002, p = 0.03), preoperative MS (β = − 0.06, p = 0.001) and BCEA at 95% and 99% of fixation points (β = − 0.12, p = 0.01; β = 0.06, p = 0.01).

Conclusions

Inverted ILM-flap technique for LMH results in good morphologic and functional outcomes. Macular hole size and microperimetric parameters as preoperative MS and BCEA have a predictive role on post-surgical visual acuity.

An Internal Limiting Membrane Plug and Gas Endotamponade for Recurrent or Persistent Macular Hole

Introduction

Recurrent or persistent macular holes (MHs) are rare today due to the tendency to carefully peel the internal limiting membrane. Conversely, their treatment is still a challenge for a vitreoretinal surgeon.

Materials and Methods

This is a retrospective, consecutive, and nonrandomized study of patients affected by recurrent or persistent MHs treated using small-gauge pars plana vitrectomy (25- or 23-gauge) and an autologous ILM plug, at the Eye Clinic of Azienda Ospedaliera Universitaria Careggi (Florence, Italy) between January 2016 and May 2018. We included 8 eyes of 8 patients in the study. Five patients had a recurrent MH while 3 had a persistent MH. The case series includes patients with myopic eyes and with large macular holes (>400 μ). Patients were followed up with ophthalmoscopic examinations and swept-source optical coherence tomography (SS-OCT).

Results

The mean age of the patients was 74 years (±4.81 standard deviation (SD)), 3 patients were men and 5 women. The average axial length was 26.28 mm (±2.84 SD). Four patients had an AL ≧ 26 mm. The mean MH diameter was 436.5 (±49.82 SD). Average preoperative best-corrected visual acuity (BCVA) was 0.81 logMAR (±0.16 SD) and 20/125 Snellen. The ILM plug has been found integrated in the MH in all the follow-ups.

Conclusion

In our study, an ILM autologous macular transplant was used successfully in 5 cases of macular hole recurrence and 3 cases of macular hole persistence. The anatomical success was achieved in all the cases; 4 patients improved their BCVA, and 4 patients maintained it. No macular alterations such as RPE or retinal atrophy/dystrophy were observed after 6 months.

Long-Term Anatomic and Functional Outcomes after Macular Hole Surgery

Aim

To evaluate the structural and functional outcomes in patients who underwent macular hole (MH) surgery in the long-term follow-up.

Materials and Methods

Forty-four eyes of 40 patients (28 females and 12 males) were examined. The examination included visual acuity, optical coherence tomography, and colour vision testing. The same evaluation was performed in 30 fellow eyes.

Results

MH closure was obtained in 42 eyes (95.45%). There was no reopening of the initially closed MHs. In long-term postoperative examination, we observed IS/OS junction defects in 28 (63.6%) eyes and ELM defects in 19 (43.2%) eyes. We found that the IS/OS junction defects correlated with the diameter of the MH (p=0.016), whereas ELM defects correlated with both the diameter of the MH (p=0.001) and duration time of the MH (p=0.008). The presence of ELM defects in OCT was the cause of inferior BCVA in long-term observation time (p=0.004). The mean BCVA before the MH surgery was 0.15. It improved significantly both in early (p < 0.001) and long-term postoperative observation (p < 0.005). Generally, the functional outcomes were better in eyes with short-time duration of the MH, when a smaller diameter (<400 μm) of the hole was measured and a V-shaped closure of the MH and the restoration of the ELM line on OCT were present. Pseudoprotanomaly was noted in 13 (35.1%) eyes. In the fellow eye group, mean BCVA was 0.95 (range, 0.6–1.0). In 3 eyes, we detected vitreomacular traction, and in 4 eyes, initial cataract. These conditions, as well as probably early stage of diabetes mellitus, influenced functional outcomes of studied eyes.

Conclusions

The anatomic and functional outcomes after macular surgery are satisfactory and improve with time. After a successful closing of the MH, the restoration of the retina progresses at a slower pace than improvement in visual acuity.

Foveal microstructure and visual outcomes of myopic macular hole surgery with or without the inverted internal limiting membrane flap technique

Purpose

The aim of this study was to determine the effect of the inverted internal limiting membrane (ILM) flap technique on the macular hole (MH) closure and foveal microstructure recovery of patients with highly myopic MH.

Methods

Pars plana vitrectomy and gas tamponade with the inverted ILM flap technique (19 eyes) or with the ILM peeling technique (21 eyes) were performed in patients with highly myopic MH with or without retinal detachment. The rate of MH closure and retinal reattachment, the reconstructive anatomical change of the foveal microstructure and the best-corrected visual acuities (BCVA) of the two groups were compared.

Results

The anatomic closure rate was statistically significantly higher in the inverted group (100%) than in the peeling group (66.7%; p=0.009). All eyes with MH retinal detachment had successful retinal reattachment in these two groups. However, the rate of the external limiting membrane (ELM) and ellipsoid zone (EZ) (p=0.020), as well as gliosis (p=0.049) in macular area, detected by OCT, was significantly greater in the inverted group than in the peeling group. The postoperative BCVA was significantly better in the eyes with ELM, EZ (p=0.031) and gliosis (p=0.008), but without hyperreflective foci (p=0.001).

Conclusions

These findings demonstrate that the inverted ILM flap technique has better efficacy than the ILM peeling technique for patients with myopic MH in closure rate, foveal microstructure and postoperative BCVA.

Comparative study of inverted internal limiting membrane (ILM) flap and ILM peeling technique in large macular holes: a randomized-control trial

Background

The anatomical success rate of macular hole surgery ranges around 93–98%. However, the prognosis of large macular holes is generally poor. The study was conducted to compare the anatomical and visual outcomes of Internal Limiting Membrane (ILM) peeling vis-a-vis inverted ILM flap for the treatment of idiopathic large Full-Thickness Macular Holes (FTMH).

Methods

This was a prospective randomized control trial. The study included patients with idiopathic FTMH, with a minimum diameter ranging from 600 to 1500 μm. The patients were randomized into Group A (ILM peeling) and Group B (inverted ILM flap). The main outcome measures were anatomical and visual outcome at the end of 6 months. Anatomical success was defined as flattening of macular hole with resolution of the subretinal cuff of fluid and neurosensory retina completely covering the fovea.

Results

There were 30 patients in each group. The mean minimum diameters in Group A and B were 759.97 ± 85.01 μm and 803.33 ± 120.65 μm respectively (p = 0.113). The mean base diameter in group A and B was 1304.50 ± 191.59 μm and 1395.17 ± 240.56 μm respectively (p = 0.112). The anatomical success rates achieved in Group A and B were 70.0 and 90.0% respectively (p = 0.125). The mean best-corrected visual acuity (BCVA) after 6 months was logMAR 0.65 ± 0.25 (Snellen equivalent, 20/89) in Group A and logMAR 0.53 ± 0.20 (Snellen equivalent, 20/68) in Group B (p = 0.060). The mean improvement in BCVA was 1.4 lines and 2.1 lines in groups A and B respectively (p = 0.353). BCVA≥20/60 was achieved by 13.3 and 20.0% in group A and B respectively (p = 0.766).

Conclusion

The anatomical and functional outcome of Inverted ILM flap technique in large FTMH is statistically similar to that seen in conventional ILM peeling.

Trial registration

Clinical Trials Registry – India (Indian Medical Research) CTRI/2017/11/010474.

Electronic supplementary material

The online version of this article (10.1186/s12886-018-0826-y) contains supplementary material, which is available to authorized users.