Subretinal Injection Using a Hinged Internal Limiting Membrane Flap Technique for Submacular Hemorrhage

To describe a hinged internal limiting membrane (ILM) flap technique designed to stabilize the retinal puncture site during pars plana vitrectomy with subretinal injection for submacular hemorrhage (SMH), and to evaluate its clinical outcomes.

In this retrospective case series, we included eight consecutive patients with eight eyes that underwent surgery for SMH using the hinged ILM flap technique at Japan Community Healthcare Organization Chukyo Hospital and Chukyo Eye Clinic between April 2022 and December 2025. Surgical indications were SMH involving the fovea with a maximum diameter of ≥3 disc diameters extending beyond the vascular arcades. During surgery, either balanced salt solution or tissue plasminogen activator was injected into the subretinal space using the hinged ILM flap technique, followed by subretinal air injection in all cases. Primary outcomes included intraoperative and postoperative complications and changes in best-corrected visual acuity (BCVA).

No intraoperative or postoperative complications, including rhegmatogenous retinal detachment, were observed. Mean BCVA improved from 1.09 logarithm of the minimum angle of resolution (logMAR) (approximately 20/250) preoperatively to 0.80 logMAR (approximately 20/125) at the final visit; however, the difference was not statistically significant (p = 0.13).

The hinged ILM flap technique may represent a practical adjunctive maneuver to stabilize the retinal puncture site during subretinal injection for SMH.