Temporal inverted internal limiting membrane flap technique for a 500 μm full-thickness macular hole: A case report

Large full-thickness macular holes (FTMH), defined by the International Vitreomacular Traction Study Group as defects of all retinal layers within the foveal region with an aperture size of 400 μm or more, remain a challenging condition with reduced anatomical closure rates using conventional techniques. We report a case managed with the temporal inverted internal limiting membrane (ILM) flap technique.

A 70-year-old female patient presented to the Outpatient Ophthalmology Clinic with decreased vision in the left eye.

Decimal Snellen best-corrected visual acuity was 0.3 (5/16) in oculus sinister (left eye) and 0.06 (3/50) in oculus dexter (right eye), and intraocular pressure was 16 mm Hg in both eyes. Optical coherence tomography (OCT) revealed an hourglass-shaped FTMH with cystic changes within the retina and rounded thickened edges, with a minimum aperture size of 500 μm. Fundus examination and OCT of the fellow (right) eye also revealed a full-thickness macular hole (MH), with a smaller aperture than the left eye.

The patient underwent 25G pars plana vitrectomy with the temporal inverted ILM flap technique, followed by fluid-air exchange and 25% sulfur hexafluoride gas endotamponade.

Follow-up OCT at 33 and 45 days after the procedure demonstrated complete closure of the MH, with a small residual fluid pocket beneath the inverted ILM flap noted at day 33. Best-corrected visual acuity was 0.1 (5/50) in oculus dexter (right eye) and 0.5 (5/10) in oculus sinister, and intraocular pressure was 15 mm Hg in both eyes at the final follow-up.

In the presented patient, 25G vitrectomy using the temporal inverted ILM flap technique resulted in short-term anatomical closure of the MH and improvement in visual acuity, consistent with previous reports of this technique in the management of large FTMH.