Retinal atrophy and eccentric macular hole after internal limiting membrane peeling: a case report

Postoperative eccentric macular hole (MH) formation is a relatively rare complication after pars plana vitrectomy (PPV) with internal limiting membrane(ILM) peeling for epiretinal membrane (ERM) or MH treatment. Herein, we report a case of eccentric MH formation following PPV with ILM peeling for MH.

A 62-year-old male presented with a 3-month history of blurred vision and metamorphopsia in the left eye. Preoperative optical coherence tomography (OCT) confirmed a full-thickness MH (minimum linear diameter: 675 μm). The patient underwent 25-gauge PPV with ILM peeling using indocyanine green (ICG, 0.25%) and inverted ILM flap placement. Postoperative OCT at one week confirmed MH closure. However, subsequent follow-ups revealed progressive inner retinal disorganization, atrophy, and cavitation. At five months, a parafoveal full-thickness eccentric macular hole (EMH) developed inferiorly. No additional interventions were pursued due to stable hole size and absence of retinal detachment.

This case highlights rare postoperative retinal atrophy and EMH formation following ILM peeling for MH repair. Potential contributors include ICG-induced photochemical toxicity, Müller cell damage from ILM peeling, and fluid shear stress. The findings underscore the need to optimize ICG protocols (reduced concentration, shorter exposure) and prioritize safer alternatives like brilliant blue G (BBG). Long-term postoperative monitoring is critical to detect delayed complications, emphasizing the balance between surgical efficacy and minimizing iatrogenic retinal injury.