Subretinal balanced salt solution injection versus the inverted internal limiting membrane flap technique for full-thickness macular holes
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Updated: Nov 2, 2026
An Alternative and Validated Injection Method for Accessing the Subretinal Space via a Transcleral Posterior Approach
Published on: December 7, 2016
Liyu Ren1,2, Xinhong Zhang1,2, Xia Wang1,2
1Tianjin Eye Hospital, Tianjin Key Lab of Ophthalmology and Visual Science, 4 Gansu Road, Heping, Tianjin, 300020, Tianjin, China.
Purpose:
To compare the anatomical and functional outcomes of internal limiting membrane (ILM) peeling combined with subretinal balanced salt solution (SR-BSS) injection with those of the inverted ILM flap technique for large idiopathic full-thickness macular holes (FTMHs), and to evaluate postoperative outer retinal integrity and foveal morphology.
Methods:
This retrospective cohort study included consecutive eyes with idiopathic FTMHs with a minimum diameter of ≥400 μm that underwent pars plana vitrectomy between March 2024 and July 2025. Eyes underwent either ILM peeling with multi-point SR-BSS injection or the inverted ILM flap technique. Outcome measures included macular hole closure rate, best-corrected visual acuity (BCVA), and optical coherence tomography parameters, including ellipsoid zone (EZ) and external limiting membrane (ELM) defect lengths and central foveal thickness (CFT).
Results:
Thirty-five eyes underwent surgery (20 SR-BSS and 15 inverted ILM flap). Three eyes in the inverted ILM flap group were excluded from the final statistical analysis because the postoperative ELM and EZ bands could not be reliably delineated, leaving 32 eyes (20 in the SR-BSS group and 12 in the inverted ILM flap group) for analysis. Primary macular hole closure was achieved in 19 of 20 eyes (95%) in the SR-BSS group and 12 of 12 eyes (100%) in the inverted ILM flap group (P = 1.00). BCVA improved significantly in both groups at 1 and 6 months, with no significant differences between groups. At 6 months, the postoperative EZ defect was significantly smaller in the SR-BSS group (P = 0.017), whereas the ELM defect and CFT did not differ significantly between groups. Type I closure occurred more frequently in the SR-BSS group than in the inverted ILM flap group. EZ and ELM defect lengths were negatively correlated with BCVA, whereas CFT was positively correlated with BCVA.
Conclusion:
SR-BSS-assisted surgery achieved a high macular hole closure rate that was not significantly different from that of the inverted ILM flap technique and was associated with a smaller EZ defect at 6 months in large idiopathic FTMHs. Postoperative visual outcomes were similar between the two groups.
