Modification of the Temporal Inverted Internal Limiting Membrane Flap in Macular Hole Surgery: Envelope Technique

This case report aims to present a modification of the temporal inverted internal limiting membrane (ILM) flap technique in macular hole surgery. The inverted ILM flap technique was first described in 2010 and was shown to yield superior functional and anatomical outcomes in large macular holes compared to traditional ILM peeling. However, flap displacement can be a major concern with the inverted ILM flap technique. In the first case, a failed large macular hole after temporal inverted ILM flap surgery was reoperated, and flap displacement was observed as the reason for failure. The displaced ILM flap was inverted again and the superior corner of the flap was tucked under the small ILM defect in the upper nasal macular area to stabilize it. Hence, it is called as “envelope modification”. Another patient with rhegmatogenous retinal detachment with coexistent macular hole underwent vitrectomy surgery with silicone oil. The retina was attached postoperatively, and the macular hole was closed with a flat-open pattern. During silicone oil removal, the envelope modification was used and the hole closed. Both patients had visual improvement. Although the inverted ILM flap technique is very effective for large macular holes, the modification described here may further improve the success rate.