Inverted internal limiting membrane flap technique for large macular holes

Area of Science:

• Ophthalmology
• Retinal Surgery
• Surgical Innovation

Background:

• Large macular holes (>400 μm) have a high risk of surgical failure, with up to 44% remaining open after one surgery.
• Flat-open macular holes, occurring in 19-39% of cases, are associated with poor visual acuity outcomes.
• Standard pars plana vitrectomy may not adequately address the complex anatomy of large macular holes.

Observation:

• A prospective, randomized clinical trial compared standard vitrectomy with an inverted internal limiting membrane (ILM) flap technique in patients with large macular holes.
• The inverted ILM flap technique involves inverting a remnant of the ILM to cover the macular hole instead of complete removal.
• Postoperative outcomes were assessed using spectral optical coherence tomography and clinical examination over 12 months.

Findings:

• Macular hole closure rates were significantly higher with the inverted ILM flap technique (98%) compared to standard surgery (88%).
• The incidence of flat-open macular holes was drastically reduced from 19% in the standard group to 2% in the inverted ILM flap group.
• Mean postoperative visual acuity at 12 months was significantly better in the inverted ILM flap group (0.28) versus the standard group (0.17) (P = 0.001).

Implications:

• The inverted ILM flap technique offers improved functional and anatomic outcomes for large macular hole repair.
• This technique effectively prevents the flat-open macular hole morphology, leading to better visual rehabilitation.
• Spectral optical coherence tomography suggests enhanced foveal anatomical restoration with the inverted ILM flap technique.