Macular hole closure patterns associated with different internal limiting membrane flap techniques

Advances in management strategies for large and persistent macular hole: An update

The standard of care to treat small- and medium-sized macular holes (<400 µm diameter) consists of a conventional transconjunctival sutureless pars plana vitrectomy followed by ILM peeling and endotamponade, mainly with gas or in some cases with silicone oil, resulting in closure rates of over 90% and good functional results. Large (>400 µm diameter), chronic and persistent macular holes remain a surgical challenge since closure rates and functional results decrease with larger macular hole diameters. Various modifications of the conventional surgical technique were introduced to improve anatomic and functional success in refractory cases not suitable for conventional macular hole surgery. These techniques comprise the positioning of tissue at the top of the hole to improve closure as performed by an inner limiting membrane flap and free flap preparation or the transplantation of autologous retinal tissue, lens capsule or amniotic membrane. For the treatment of very large and persistent macular holes, the induction of a localized retinal detachment at the posterior pole by subretinal injection of balanced salt solution and a subsequent attenuation of the rim of the hole during fluid-air exchange has been suggested as a promising surgical technique. In particular, accurate patient education about the expected surgical outcome in this specific group of patients appears important.

Comparison of the use of internal limiting membrane flaps versus conventional ILM peeling on post-operative anatomical and visual outcomes in large macular holes

BACKGROUND

Idiopathic full-thickness macular hole (iFTMH) closure rates following conventional vitrectomy, gas tamponade and internal limiting membrane (ILM) peeling decrease when the minimum linear diameter (MLD) ≥ 500 microns. ILM flap creation has been proposed to improve closure in larger holes. This study evaluated the anatomical and functional impact of ILM flap introduction to routine practice in iFTMH ≥500 microns.

METHODS

Retrospective, interventional analysis of prospectively collected data of 191 eyes from consecutive surgeries for primary iFTMH ≥500 microns performed by two surgeons between June 2018 and June 2022, during which both surgeons replaced ILM peeling with ILM flap creation. Post-operative best-corrected visual acuity (BCVA) and anatomical closure were compared between Group 1 (ILM peel) and Group 2 (ILM flap) in an intention-to-treat analysis.

RESULTS

Rates of iFTMH closure were greater in the ILM flap group (77/80; 96.3%) than the ILM peel group (94/110; 85.5%) (OR = 4.37, 95% CI = 1.23-15.55, p = 0.023). A non-significant increase in post-operative BCVA improvement was observed in the ILM flap group (p = 0.084). There was no statistically significant difference in final BCVA (p = 0.83). Multivariate logistic regression found only MLD (OR = 0.993, 95% CI = 0.989-0.997, p = 0.001) and ILM flap group (OR = 5.795, 95% CI = 1.313-25.570, p = 0.020) predicted primary closure.

CONCLUSION

ILM flap creation improves closure rates in larger holes and should be considered routinely in iFTMH ≥500 microns. Whether ILM flaps affect post-operative visual function remains uncertain.

Anatomical and functional results after vitrectomy with conventional ILM peeling versus inverted ILM flap technique in large full-thickness macular holes

BACKGROUND

Aim of the study was to compare success rate and functional outcome following pars plana vitrectomy (PPV) with conventional internal limiting membrane (ILM) peeling versus ILM flap technique for full-thickness idiopathic macular holes (FTMH).

METHODS

Retrospective analysis of consecutive eyes with FTMH having undergone vitrectomy with sulfur hexafluoride (SF6) endotamponade 25% at the University Medical Center Rostock, Germany (2009-2020). Eyes were divided according to applied surgical technique (ILM peeling [group P] versus ILM flap [group F]). Inclusion criteria were macular hole base diameters (MH-BD) ≥ 400 μm plus axial length ≤ 26.0 mm. Each group was divided into two subgroups based on macular hole minimum linear diameter (MH-MLD): ≤ 400 μm and > 400 μm. Exclusion criteria were FTMH with MH-BD < 400 μm, trauma, myopia with axial length > 26.0 mm or macular schisis. Demographic, functional, and anatomical data were obtained pre- and postoperatively. Preoperative MH-BD and MH-MLD were measured using optical coherence tomography (OCT; Spectralis®, Heidelberg Engineering GmbH, Heidelberg, Germany). Main outcome parameter were: primary closure rate, best-corrected visual acuity (BCVA), and re-surgery rate.

RESULTS

Overall 117 eyes of 117 patients with FTMH could be included, thereof 52 eyes underwent conventional ILM peeling (group P) and 65 additional ILM flap (group F) technique. Macular hole closure was achieved in 31 eyes (59.6%) in group P and in 59 eyes (90.8%) in group F (p < 0.001). Secondary PPV was required in 21 eyes (40.4%) in group P and in 6 eyes (9.2%) in group F. Postoperative BCVA at first follow-up in eyes with surgical closure showed no significant difference for both groups (MH-MLD ≤ 400 μm: p = 0.740); MH-MLD > 400 μm: p = 0.241).

CONCLUSION

Anatomical results and surgical closure rate following ILM flap technique seems to be superior to conventional ILM peeling for treatment of FTMH.

Modification of the inverted flap technique compared to conventional internal limiting membrane peeling in complete macular hole surgery

AIM

To describe the efficacy of a modification of the superior inverted flap technique, with maculorrhexis, in vitrectomy for full-thickness macular hole (MH) surgery compared to internal limiting membrane peeling (ILM).

METHODS

Retrospective and comparative study of patients with MH. In group A, a superior ILM flap is created to cover the macular hole, and in group B conventional ILM peeling was performed.

RESULTS

A total of 80 eyes were included (44 group A and 36 group B). MH closure occurred in 100% in group A and 91.67% in group B (p = 0.0869). There were more U-type closures in group A(90.91%) than in group B(58.33%), p = 0.0017. Both groups showed Best corrected visual acuity (BCVA) improvement at 3 and 6 months. At 3 months BCVA in group A was significantly better but at 6 months results were similar. Ellipsoid layer (EZ) recovery at 6 months was achieved in 81.82% patients in group A and 52.78% in B (p = 0.005), and external limiting membrane in 81.82% in group A and 69.44% in B (p = 0.1957).

CONCLUSIONS

The superior inverted flap maculorrhexis technique is suitable for idiopathic MH treatment, with better anatomical and non-inferior functional results than the classic ILM peeling. It achieves functional recoveries earlier, better BCVA and greater gains at 3 months compared to the classic ILM peeling. It also obtains a higher number of U-shaped closures and higher EZ restorations.

Inverted Internal Limiting Membrane Flap versus Internal Limiting Membrane Insertion Technique for Large Macular Holes: A Meta-Analysis

PURPOSES

This meta-analysis aimed to compare and evaluate the morphological and functional outcomes between the inverted internal limiting membrane (ILM) flap and ILM insertion techniques in the treatment of large macular holes (MHs).

METHODS

The PubMed, Embase, and Cochrane Library databases were searched for relevant studies comparing the two techniques for the treatment of large MHs. The primary outcome measures included the MH closure rate, preoperative and postoperative best-corrected visual acuity (BCVA), MH closure patterns, and external limiting membrane (ELM) and ellipsoid zone (EZ) recovery. Statistical analyses were performed using RevMan 5.3 software.

RESULTS

Two randomized controlled trials and four retrospective studies were included in this meta-analysis. The MH closure rate did not significantly differ between the two groups (P = .93). Postoperative BCVA was not significantly different between the two groups at 3 months (P = .20) or 6 months (P = .51). ELM and EZ recovery were also similar between the two groups. However, the results for postoperative BCVA and outer retinal structure recovery tended to favor the ILM flap group based on the forest plot. There was no significant difference between the two groups for the U-shape (P = .26), V-shape (P = .65), and W-shape closure types (P = .38).

CONCLUSIONS

Our meta-analysis provides evidence that the MH closure rate and visual function outcomes are similar between the ILM flap and ILM insertion techniques in large MHs. However, based on the forest plot, postoperative BCVA and outer retinal layer reconstruction tended to favor the ILM flap technique. Further studies with larger sample sizes are required to confirm the superiority of the ILM flap to the ILM insertion technique.

Microstructural and microperimetric comparison of internal limiting membrane peeling and insertion in large idiopathic macular hole

BACKGROUND

The internal limiting membrane (ILM) insertion technique was widely used to treat large macular hole (MH) for the high closure rate. However, the prognosis of closed MH after ILM insertion compared to ILM peeling remains controversial. This study aimed to compare foveal microstructure and microperimeter in large idiopathic MH surgically closed by ILM peeling and ILM insertion.

METHODS

This retrospective, non-randomized, comparative study included patients with idiopathic MH (minimum diameter ≥ 650 μm) who underwent primary pars plana vitrectomy (PPV) with ILM peeling or ILM insertion. The initial closure rate was recorded. Patients with initially closed MHs were divided into two groups according to the surgery methods. The best-corrected visual acuity (BCVA), optical coherence tomography (OCT) and microperimeter-3 (MP-3) outcomes of two groups were compared at baseline, 1 and 4 months postoperatively.

RESULTS

For idiopathic MH (minimum diameter ≥ 650 μm), ILM insertion had a significantly higher initial closure rate than ILM peeling (71.19% vs. 97.62%, P = 0.001). Among 39 patients with initially closed MHs who were on regular follow-up, twenty-one were assigned to the ILM peeling group and 18 to the ILM insertion group. Postoperative BCVA improved significantly in both groups. The final BCVA (logMAR) (0.40 vs. 0.88, P < 0.001), macular hole sensitivity (19.66 dB vs. 14.14 dB, P < 0.001), peripheral sensitivity of macular hole (24.63 dB vs. 21.95 dB, P = 0.005), and fixation stability (FS) within 2 degrees (82.42% vs. 70.57%, P = 0.031) were significantly better and external limiting membrane (ELM) defect (330.14 μm vs. 788.28 μm, P < 0.001) and ellipsoid zone (EZ) defect (746.95 μm vs. 1105.11 μm, P = 0.010) were significantly smaller in the ILM peeling group than in the ILM insertion group.

CONCLUSION

For initially closed MHs (minimum diameter ≥ 650 μm), both ILM peeling and ILM insertion significantly improved the microstructure and microperimeter in the fovea. However, ILM insertion was less efficient at microstructural and functional recovery after surgery.

DIFFERENCES IN ANATOMICAL AND VISUAL OUTCOMES AMONG THREE INTERNAL LIMITING MEMBRANE TECHNIQUES TREATING EXTRA-LARGE IDIOPATHIC MACULAR HOLES

PURPOSE

To compare the anatomical and visual outcomes of extra-large idiopathic macular holes treated with internal limiting membrane peeling and two inverted internal limiting membrane flap techniques, namely insertion and cover technique.

METHODS

Patients with idiopathic macular holes (minimum linear diameter ≥ 650 µm) were divided into peeling group, insertion group, and cover group. The initial closure rate, final length of external limiting membrane and ellipsoid zone recovery, and best-corrected visual acuity were evaluated.

RESULTS

A total of 124 eyes were included, and the average follow-up was 7.2 months. All the baseline characteristics were comparable among the three groups. Initial closure rate of the peeling group, the insertion group, and the cover group was 65.0% (26/40), 97.6% (41/42), and 90.5% (38/42), respectively (P < 0.001). In closed idiopathic macular holes, the peeling group and the cover group exhibited significantly longer length of external limiting membrane recovery than the insertion group (P < 0.001), and the peeling group exhibited significantly longer length of ellipsoid zone recovery than the other two groups (P = 0.021). The peeling group and the cover group exhibited significantly better best-corrected visual acuity improvement than the insertion group (P = 0.009).

CONCLUSION

For extra-large idiopathic macular holes, cover technique surpasses internal limiting membrane peeling technique in closure rate and outperforms insertion technique in anatomical and functional recovery, whereas insertion technique may adversely affect the recovery of foveal microstructure and best-corrected visual acuity.

Modified perfluorocarbon liquid/internal limiting membrane interface staining in myopic macular hole retinal detachment

PURPOSE

To demonstrate a modified technique of perfluorocarbon liquid (PFCL)/internal limiting membrane (ILM) interface staining in patients affected by macular hole retinal detachment (MHRD) in the setting of high myopia.

METHODS

Two-surgeon retrospective case series and review of surgical videos with step-by-step technique analysis.

RESULTS

Our modified technique was proficiently employed to treat 9 highly myopic patients affected by MHRD. Successful staining and peeling of the ILM with the creation of an inverted flap was achieved in all cases. A limited number of dye injections required to stain the ILM was noted. No subretinal dye migration or other intra- and postoperative complications were recorded.

CONCLUSION

Modified PFCL/ILM interface staining is a surgically efficient technique potentially reducing the risk of iatrogenic damage, including the toxicity of vital dyes to the retinal pigment epithelium (RPE) in myopic MHRD.

ILM peeling with ILM flap transposition vs. classic ILM peeling for small and medium macula holes-a prospective randomized trial

Background

The aim of the present study was to compare macular hole closure rates of patients with small and medium-sized macular holes who underwent vitrectomy with internal limiting membrane (ILM) peeling combined with ILM flap transposition over the macular hole, compared with classic ILM peeling.

Methods

This prospective randomized trial was designed as a pilot study with two groups: ILM peeling with ILM flap transposition over the macular hole vs. classic ILM peeling.

Results

Among 20 patients recruited, complete analysis could be performed for 16 patients. The macular hole closure rates were 100% in both groups, without significant differences with respect to postsurgical subfoveal hyporeflective zones (p = 1.0, Fisher's exact test), postsurgical visual acuity (p = 0.7, t-test), and postsurgical irregularities of the ellipsoid zone (p = 1.0, Fisher's exact test).

Conclusion

Vitrectomy with ILM peeling combined with ILM flap transposition over the macular hole and classic ILM peeling are both successful methods for the repair of macular holes of small and medium size and are associated with comparable outcomes.

Comparative Study of Conventional Inverted ILM Flap Covering and ILM Flap Filling Technique in Idiopathic Macular Hole Treatment: A Meta-Analysis and Systematic Review

Objective

This meta-analysis was performed to evaluate the anatomical efficacy and functional improvement of the conventional inverted internal limiting membrane (ILM), flap covering technique, and ILM flap filling technique for patients with idiopathic macular hole (MH).

Methods

Literature from Pubmed, Embase, Cochrane Central Register of Controlled Trials, and Web of Science were comprehensively retrieved. The primary outcomes included the MH closure rate and postoperative best-corrected visual acuity (BCVA). The secondary outcomes were the proportion of external limiting membrane (ELM) and ellipsoid zone (EZ) defect recovery. Pooled odds ratios (ORs), weighted mean differences (WMDs), and 95% confidence intervals (CIs) were calculated using STATA 17.0 software.

Results

7 studies that contained 139 eyes in the inverted ILM flap covering group and 121 eyes in the ILM flap filling group were selected. Pooled data suggested that the surgical treatment resulted in an overall MH closure rate of up to 97.12% (135/139 eyes) in the inverted ILM flap covering group and 99.17% (120/121 eyes) in the filling group, with no significant difference between the 2 groups (OR = 1.98, 95% CI: 0.55 to 7.09, and P=0.29). Similarly, the 2 techniques demonstrated equal effectiveness on the anatomical closure in MH with the average diameter smaller than 650 μm (OR = 2.17, 95% CI: 0.48 to 9.77, and P=0.31) and larger than 650 μm (OR = 1.58, 95% CI: 0.14 to 17.37, and P=0.71). However, compared with the filling technique, the inverted ILM flap covering technique was superior in postoperative BCVA (WMD = 0.11, 95% CI: 0.04 to 0.18, and P=0.0017) and presented a significantly higher proportion of reconstitution of ELM (OR = 0.02, 95% CI: 0.00 to 0.08, and P < 0.0001) and EZ (OR = 0.11, 95% CI: 0.04 to 0.32, and P=0.0001).

Conclusion

The inverted ILM flap covering technique was associated with the superior reconstitution of outer layers of the retina, including ELM and EZ, and more improvement in postoperative BCVA than the ILM flap filling technique.

Comparison of Idiopathic Macular Hole Interventions Using Frequency Domain Optical Coherence Tomography and Optical Coherence Tomography Angiography

Objective

We aimed to determine the efficacy of different idiopathic macular hole treatment methods to improve recovery time and patient outcomes using Frequency Domain Optical Coherence Tomography (SD-OCT) and Optical Coherence Tomography Angiography (OCTA).

Methods

This retrospective study included patients with idiopathic macular hole who were admitted to our hospital between 1st January 2019 and 31st October 2021. The control group was treated with internal limiting membrane tamponade, and the study group was treated with clamshell therapy. Treatment conditions (internal limiting membrane treatment duration and hole closure rate), best corrected visual acuity (BCVA) before and after surgery, OCTA measurements, and SD-OCT were assessed. The retinal nerve fiber layer (RNFL), retinal ganglion cell layer (GCL), and retinal pigment epithelium (RPE) thicknesses were also analyzed.

Results

The treatment time and hole closure rate of the internal limiting membrane in the study group were higher than those in the control group. The curative effect of the study group was better than that of the control group. The postoperative DCP blood vessel density in both groups was higher than that before operation, and the study group was higher than the control group. The FAZ area and circumference were lower than those before surgery, and the study group was lower than the control group. At 3 months after operation, the thickness of DIOA, nasal temporal RNFL, and GCL were decreased in both groups, and the observed values in the study group were lower than those in the control group. At 3-month follow-up, there was no significant difference in RPE thickness between the two groups.

Conclusion

Flip and cover therapy is the most effective treatment. SD-OCT and OCTA provide an objective basis for clinical intervention by comparing the effects of different procedures on the retinal condition of patients.

INVERTED INTERNAL LIMITING MEMBRANE FLAP TECHNIQUE FOR MACULAR HOLE COEXISTENT WITH RHEGMATOGENOUS RETINAL DETACHMENT

PURPOSE

To report the clinical features and treatment outcomes of patients with macular hole coexistent with rhegmatogenous retinal detachment surgically treated with pars plana vitrectomy and inverted internal limiting membrane flap technique.

METHODS

Eleven consecutive patients with rhegmatogenous retinal detachment and macular hole who underwent vitrectomy and internal limiting membrane peeling with the inverted flap technique between December 2017 and February 2021 were retrospectively evaluated. The main outcome measures were retinal reattachment rate, macular hole closure rate, and postoperative best-corrected visual acuity. A nonsystematic literature review was performed to compare the study outcomes with those previously reported.

RESULTS

The primary retinal reattachment rate was 90% (10/11) with one surgery and 100% with 2 surgical procedures. Macular hole closure was achieved in all patients (11/11). All patients showed an improvement in visual acuity at the final postoperative visit, and the mean postoperative best-corrected visual acuity was 0.60 ± 0.32 logarithm of the minimum angle of resolution (20/80 Snellen equivalent).

CONCLUSION

Vitrectomy with the inverted internal limiting membrane flap technique achieved not only favorable anatomical retinal reattachment rates but also an encouraging recovery of central macular anatomy and visual function in patients with macular hole coexistent with rhegmatogenous retinal detachment.

Macular Holes: Main Clinical Presentations, Diagnosis, and Therapies

Macular holes are a spectrum of retinal diseases that comprehends full-thickness macular holes (FTMHs), refractory/recurrent macular holes, lamellar macular holes (LMHs), myopic macular holes (MMHs), traumatic macular holes, and macular holes secondary to other retinal pathologies or injuries. There are various classifications of the subtypes of macular hole, and only in recent times researchers defined a common nomenclature, especially thanks to the evolution in retinal imaging, offered by new instruments like the swept-source OCT. The proposed therapies for macular holes are different and range from a “wait-and-see” approach to the vitrectomy, with different results in each subtype of macular hole. This narrative review has the purpose to investigate the available evidence in literature to give a summary of the knowledge about these retinal pathologies.

Spotlight on the Internal Limiting Membrane Technique for Macular Holes: Current Perspectives

Pars plana vitrectomy has become the standard procedure for primary macular holes (MHs) repair, including the removal of the posterior cortical vitreous, the stripping of eventual epiretinal membranes, and finally an intraocular gas tamponade. During this procedure, peeling the internal limiting membrane (ILM) has been proven to increase closure rates and avoid postoperative reopening in several researches. In fact, even in large MHs more than 400 µm, the advantage of peeling off the ILM was highlighted by better anatomical closure rates. Nevertheless, some authors suggested that ILM peeling is not always essential, because it generates various side effects in retinal structure and function. Furthermore, the ideal amount of ILM peeling and the most effective strategies for removing the ILM are still subject of research. Different surgical modifications have been reported as alternatives to traditional peeling in certain clinical settings, including ILM flaps, ILM scraping, and foveal sparing ILM peeling. As regards large MHs, the introduction of ILM inverted flap appeared as a game changer, offering a significantly higher >90% closure rate when compared to traditional ILM peeling. Modifications to inverted ILM flap procedures have been claimed in recent years, in order to define the best area and direction of ILM peeling and its correlation with functional outcomes. Moreover, several innovations saw the light in the setting of recurrent MHs, such as ILM free flap transposition, inverted ILM flap combined autologous blood clot technique, neurosensory retinal flap, and human amniotic membrane (HAM) plug, claiming higher anatomical success rate also in those complex settings. In conclusion, the aim of this review is to report how the success rate of contemporary macular surgery has grown since the turn of the century, especially for big and chronic MHs, analyzing in which way ILM management became a crucial point of this kind of surgery.

Long-Term Continuous Assessment of Internal Limiting Membrane Filling Induced Super-Large Macular Hole Healing

PURPOSE

To assess the long-term continuous anatomical and functional healing process of a super-large full-thickness macular hole (FTMH) after internal limiting membrane (ILM) filling and air tamponade.

DESIGN

Prospective, interventional case series.

METHODS

Pars plana vitrectomy with ILM filling and air tamponade was performed in eyes with idiopathic super-large FTMH (> 900 µm). Patients were divided into 3 groups according to the macular hole (MH) diameter: group A, < 1000 µm; group B, 1000 to 1100 µm; and group C, > 1100 µm. The MH closure pattern was analyzed using optical coherence tomography. The preoperative and postoperative macular hole sensitivity, parafoveal sensitivity, and fixation status were assessed using a Microperimeter-3. The preoperative and postoperative best corrected visual acuity were measured. A monthly follow-up was conducted for 15 months postoperatively.

RESULTS

Ninety-seven eyes from 96 consecutive patients with super-large FTMH were included in the study. Primary closure was seen in 93 of 97 eyes (95.88%), in which 88 of 97 eyes (90.72%) had a closed MH 1 week after surgery. The MH closure pattern continuously improved and significantly differed in the 3 groups (P < .05). Significant improvements in best corrected visual acuity (P < .01), parafoveal sensitivity (P < .05), and fixation stability (P < .01) were observed in all groups.

CONCLUSIONS

Super-large FTMH (> 900 µm) closed promptly within 1 week postoperatively after ILM filling and air tamponade. The morphological and functional improvement lasted over an extended period postoperatively. No central scotoma enlargement was found regardless of the closure patterns, and there was significant retinal sensitivity and fixation status improvement.

Impact of the Inverted Internal Limiting Membrane Flap Diameter on Large Idiopathic Macular Hole Closure: Comparative Randomized Study

BACKGROUND AND OBJECTIVE

To study the impact of the size of internal limiting membrane inverted flap on the rate and timing of large idiopathic macular hole (MH) closure.

PATIENTS AND METHODS

A prospective randomized comparative study included patients with large idiopathic MH. Eligible eyes underwent pars plana vitrectomy with either inverted small flap (SF < 2 disc diameters) or inverted large flap (LF from 2 to 4 disc diameters). The primary outcome measure included the rate of MH closure at the sixth month. Secondary outcome measures included the timing of MH closure and best-corrected visual acuity.

RESULTS

Twenty-five eyes were included: 13 in the SF group and 12 in the LF group. At 6 months, the rate of closure was 84.6% in the SF group and 91.6% in the LF group, with no significant difference. Timing of closure was significantly shorter with LF, with better postoperative best-corrected visual acuity.

CONCLUSION

LF offered a shorter duration for closure with better visual outcomes in large idiopathic MH. [Ophthalmic Surg Lasers Imaging Retina. 2022;53:103-107.].

Effect of inverted internal limiting membrane flap technique on small-medium size macular holes

Inverted internal limiting membrane (ILM) flap technique was developed to achieve macular hole (MH) closure in large MH and refractory cases. In this study, we evaluate the effect of the technique for small-medium size MH. We recruited patients who underwent vitrectomy for small-medium size (< 400 μm) MH with either inverted ILM flap technique (flap group) or with conventional ILM peeling (peeling group). Using propensity score, 21 eyes of 21 patients in the peeling group were matched against 21 eyes of 21 patients in the flap group. We compared MH closure rate, postoperative visual acuity, and recovery of the external limiting membrane (ELM) and ellipsoid zone (EZ). The MH closure rate was not different between the two groups (flap vs peeling: 90% vs 100%, P = 0.49). Whereas there was no significant difference in visual acuity improvement between the two groups, the flap group showed more disruption of the ELM 3 months after surgery and of the EZ at 3 and 6 months after surgery (P = 0.02, P = 0.03, and P = 0.04, respectively). The result suggested that inverted ILM flap technique does not have additional benefits for small-medium size MHs and may delay recovery of retinal integrity.

Inverted Internal Limiting Membrane Flap vs Complete Internal Limiting Membrane Peeling for Large Macular Holes in Nonposturing Surgery

Purpose:

This study compared anatomical and functional outcomes of the inverted internal limiting membrane flap (ILMF) technique with complete ILM peeling (ILMP) in nonposturing surgery for large, full-thickness macular holes (MHs).

Methods:

This was a retrospective, comparative, single-surgeon study. Eyes with idiopathic large full-thickness MHs (minimum diameter > 400 μm) were included. A total of 46 patients including 22 ILMF cases and 24 ILMP cases were analyzed. No positioning instructions were advised postoperatively.

Results:

Primary hole closure was achieved in all patients (100%) in both groups. Mean logMAR visual acuity (VA) improved significantly in both groups compared with the preoperative values (ILMF: 0.60 [SD, 0.26] postoperatively, vs 0.93 [SD, 0.3] preoperatively, P = .032; ILMP: 0.43 [SD, 0.22] postoperatively vs 0.83 [SD, 0.16] preoperatively, P < .01). However, ILMP showed a statistically significant improvement in VA compared with ILMF ( P = .02).

Conclusions:

All MHs in both groups closed after surgery (100%). There was a statistically significant improvement of VA in the ILMP group compared with the ILMF group ( P = .02). Not posturing after surgery did not compromise surgical success in both groups.

Update on surgical management of complex macular holes: a review

Modern surgical interventions effectively treat macular holes (MHs) more than 90%. Current surgical treatment for MHs is pars plana vitrectomy with epiretinal membrane, internal limiting membrane (ILM) peeling, gas endotamponade, and prone posturing postoperatively. However, a small subset of MHs imposes challenges to surgeons and frustrations on patients. A narrative review was performed on the surgical treatment of challenging MHs including large and extra-large MHs, myopic MHs with or without retinal detachment, and chronic and refractory MHs. There are robust data supporting inverted ILM flap as the first-line treatment for large idiopathic MHs and certain secondary MHs including myopic MHs. In addition, several studies had shown that ILM flap manipulations in combination with surgical adjuncts increase surgical success, especially in difficult MHs. Even in eyes with limited ILM, surgical options included autologous retinal graft, human amniotic membrane, and creation of a distal ILM flap that can assist in MH closure even though the functional outcome may be affected by the MH chronicity. Despite relative success anatomically and visually after each technique, most techniques require a long-term study to analyze their safety profile and to establish any morphological changes of the MH plug in the closed MHs.

Factors Associated with Anatomic Failure and Hole Reopening after Macular Hole Surgery

A macular hole (MH), particularly an idiopathic macular hole (IMH), is a common cause of central vision loss. Risk factors for nonidiopathic MH include high myopia, cystoid macular edema, inflammation, and trauma. MH is primarily diagnosed using slit-lamp microscopy and optical coherence tomography (OCT). Half of the patients with stage I MHs are treated conservatively and may show spontaneous resolution. The main treatment methods for MHs currently include vitrectomy and stripping of the internal limiting membrane (ILM). However, in some patients, surgery does not lead to anatomical closure. In this review, we summarize the factors influencing the anatomical closure of MHs and analyze the potential underlying mechanisms.

[iOCT in clinical use : Correlation of intraoperative morphology and postoperative visual outcome in patients with full thickness macular hole]

Hintergrund

Die Beurteilung der intraoperativen Veränderung der Netzhautmorphologie, insbesondere des vitreoretinalen Überganges, ist mithilfe der intraoperativen optischen Kohärenztomografie (iOCT) möglich geworden.

Ziel der Arbeit

Um die Bedeutung der intraoperativen Morphologie beim durchgreifenden Makulaforamen (MF) für das postoperative funktionelle Ergebnis zu evaluieren, wurde eine retrospektive, klinische Beobachtungsstudie durchgeführt.

Material und Methoden

Die Netzhautmorphologie wurde in 32 Augen von 32 konsekutiven Patienten mit durchgreifendem Makulaforamen mittels iOCT zu verschiedenen Zeitpunkten während der Operation beobachtet. Die Veränderungen wurden anschließend mit dem postoperativen funktionellen Ergebnis korreliert.

Ergebnisse

Nach Induktion der hinteren Glaskörperabhebung (HGA) reduzierte sich der Makulaforamen-Index (MHI) um −0,05 (p = 0,01), die basale Foramenbreite (FB) stieg um +99,4 μm (SD = 197,8 μm; p = 0,04). Die Verschlussrate betrug 100 % zum Zeitpunkt der ersten postoperativen Vorstellung nach im Mittel 73 Tagen, der postoperative Visus verbesserte sich signifikant (p < 0,05).

Es zeigte sich eine signifikant positive Korrelation von intraoperativer Morphologie und postoperativem Ergebnis zwischen einem niedrigen MHI und einem besseren postoperativen Visus (SKK = 0,50; p = 0,02), zwischen einer großen FB und einem besseren postoperativen Visus (SKK = 0,43; p = 0,05) sowie zwischen einer breiten Apertur nach HGA und einem größeren Visusanstieg postoperativ (SKK = 0,44; p = 0,03).

Diskussion

Wir konnten eine Abflachung sowie eine Verbreiterung des MF durch Lösen der vitreoretinalen Zugkräfte beobachten. Aufgrund des Zusammenhangs zwischen einer großen intraoperativen FB mit einem besseren postoperativen Visus scheint die intraoperative Relaxierung der Netzhaut bedeutsam.

Contractility of temporal inverted internal limiting membrane flap after vitrectomy for macular hole

We investigated the postoperative visual outcomes and morphological changes of the internal limiting membrane (ILM) flap, in patients who underwent the temporal inverted ILM flap technique for macular hole (MH). Between August 2018 and February 2020, 22 eyes of 22 patients with idiopathic or myopic MH who underwent vitrectomy with ILM flap were included in this study and followed-up for more than 6 months. Postoperative MH status, comparison of best-corrected visual acuity (BCVA) before and 6 months after surgery, changes in the ILM flap area at 1 and 6 months postoperatively, and the factors related to changes in ILM flap size, were analyzed. MH closure was achieved in all of the patients. The BCVA at 6 months postoperatively (0.18 ± 0.15) was significantly better than the preoperative BCVA of 0.63 ± 0.37 (P < 0.001, paired t test). The area of the ILM flap decreased significantly from 3.25 ± 1.27 mm² at 1 month to 3.13 ± 1.23 mm² at 6 months (P = 0.024, Wilcoxon signed-rank test). Two eyes showed an ILM flap contraction of more than 20%, and one eye required reoperation due to an increase in metamorphopsia and decreased visual acuity. Among age, sex, ILM flap area at 1 month, preoperative BCVA, and axial length, ILM flap contraction was correlated with patient age and ILM flap area. Although vitrectomy with the inverted ILM flap technique confers a good visual outcome, the ILM flap may contract in younger patients.

EFFECT OF INVERTED INTERNAL LIMITING MEMBRANE FLAP ON CLOSURE RATE, POSTOPERATIVE VISUAL ACUITY, AND RESTORATION OF OUTER RETINAL LAYERS IN PRIMARY IDIOPATHIC MACULAR HOLE SURGERY

PURPOSE

To investigate the role of an internal limiting membrane (ILM) flap in macular hole (MH) surgery on closure rate, visual acuity, and integrity of the outer retinal layers.

METHODS

Retrospective, nonrandomized interventional analysis in which 117 eyes of 117 patients were included who had undergone pars-plana vitrectomy (PPV) and gas tamponade for primary idiopathic MH >400 µm with either conventional ILM peeling or with inverted ILM flap technique at The Royal Liverpool University Hospital between January 2016 and April 2018. Main outcome measures were closure of MH, best-corrected visual acuity (BCVA) at 3, 6, and 12 months, and restoration of external limiting membrane and ellipsoid zone (EZ) using optical coherence tomography.

RESULTS

Macular hole closure rate was significantly higher in patients with an ILM flap (67/68; 98.53%) than in those with conventional ILM peeling (43/49; 87.76%) (P = 0.02). Both groups showed significant improvements in their preoperative to postoperative BCVA at 3 months from 1.07 (0.43) logarithm of the minimum angle of resolution (logMAR) (20/235 Snellen) to 0.71 (0.34) logMAR (20/103 Snellen) (P <0.001), but there was no significant difference between the two groups (P = 0.45, P = 0.71). We found significant associations between postoperative BCVA and preoperative BCVA (P < 0.01) and the integrity of the EZ (P < 0.01). In 35 patients who had follow-up to 12 months, there was a significant improvement in BCVA between 3, 6, and 12 months from 0.73 (0.45) logMAR (20/107 Snellen) to 0.53 (0.24) logMAR (20/68 Snellen) and to 0.35 (0.18) logMAR (20/45 Snellen), respectively (P < 0.01). There was no significant difference at these time periods between the two groups (P = 0.62, P = 0.21, P = 0.31). The integrity of the EZ also improved significantly between 3, 6, and 12 months (P = 0.01), irrespective of the presence of an ILM flap (P = 0.58), but with a trend toward delay in restoration in those patients with an ILM flap. The improvement in BCVA at 12 months, taking into account the age of the patient, size and duration of the MH, presence of an ILM flap, and preoperative BCVA was dependent on the state of the EZ (P = 0.01).

CONCLUSION

In patients undergoing primary pars-plana vitrectomy for MH >400 µm, the presence of an inverted ILM flap was associated with a significantly higher closure rate than a conventional ILM peeling. Best-corrected visual acuity showed a strong correlation with the integrity of the EZ and both improved significantly between 3, 6, and 12 months, irrespective of the presence of an ILM flap.

Current management strategies for atypical macular holes

This review evaluates the current surgical management options for refractory and atypical macular holes (MH) and proposes a treatment paradigm for approaching complex cases. A review of literature was performed to deliver a thorough discussion of the epidemiology and pathophysiology of MH as well as the historic evolution of surgical management strategies. With this context established, an update on recent surgical advances for management of large, chronic, and highly myopic MH is provided. New small MH may be adequately treated with pars plana vitrectomy, while those ≥300 μm should undergo internal limiting membrane (ILM) peel. For MH ≥400 μm with risk factors for failure, primary intervention should involve creation of an ILM flap and various methods of flap creation are discussed. For very large MH ≥700 μm or in refractory cases, autologous retinal transplants and other recently proposed procedures should be considered. While typical MHs enjoy high initial surgical success rates, atypical and refractory MH require additional intraoperative and postoperative considerations to maximize surgical success and optimize vision. With many techniques at the surgeon's disposal, patient selection becomes critical to improving outcomes.

Viscoelastic-assisted inverted cover and free ILM flap techniques

statement: Surgical technique: an innovative way of using cohesive viscoelastic to stabilize the ILM flap during the cover inverted-flap and free-flap procedures.Summary statement: Surgical technique: an innovative way of using cohesive viscoelastic to stabilize the ILM flap during the covering step in the inverted-flap and free-flap procedures.

Anatomical and Functional Outcomes in Eyes with Idiopathic Macular Holes that Underwent Surgery Using the Inverted Internal Limiting Membrane (ILM) Flap Technique Versus the Conventional ILM Peeling Technique

INTRODUCTION

To evaluate the anatomical and functional outcomes of the inverted internal limiting membrane (ILM) flap technique (IFT) in macular holes (MHs), especially in MHs with a macular hole index (MHI) < 0.5.

METHODS

This was a retrospective comparative study. Patients with idiopathic MHs who underwent either the IFT or conventional ILM peeling (CP) were investigated. The main outcomes included the MH closure rate, best corrected visual acuity (BCVA), and recovery rates of the external limiting membrane (ELM) and ellipsoid zone (EZ) at 1, 3, and 6 months postoperatively.

RESULTS

Forty-eight eyes of 48 patients who underwent the IFT (n = 29, Group A) or CP (n = 19, Group B) were included. The mean minimal diameter was 522.00 ± 208.08 µm. The closure rate was 100.0% in Group A and 94.7% in Group B (P = 0.396). The mean BCVA and EZ and ELM recovery rates improved significantly in both groups postoperatively. No significant differences in BCVA or the EZ or ELM recovery rates were found between the two groups. Of the 39 eyes whose MHI was < 0.5, 25 underwent the IFT, and 14 underwent CP. Comparing the results of the closure rate, BCVA and recovery rates of the EZ and ELM between groups were similar to those in 48 eyes.

CONCLUSION

Both the IFT and CP can achieve a high closure rate, with no significant difference in ordinary idiopathic MHs. The IFT does not seem to achieve better anatomical and functional outcomes than CP. The IFT should be used conservatively in ordinary non-refractory MH surgery.

[Biomarkers in full-thickness and lamellar defects of the macula]

BACKGROUND

Biomarkers are characteristic biological measurable signs and objective parameters to detect the state of health. Besides functional and temporal factors, imaging biomarkers play an increasingly important role. In full-thickness and lamellar defects of the macula numerous imaging parameters have been described. This knowledge resulted in new classifications for both clinical pictures, which are based on important biomarkers of these clinical pictures and characteristic features of described subtypes.

METHODS

Imaging biomarkers for full-thickness and lamellar macular defects are described with respect to the classification and their functional prognostic importance. The importance of these biomarkers is presented.

RESULTS

The current classification of full-thickness and lamellar macular defects is based on structural biomarkers. Biomarkers are important for prognostic and therapeutic evaluation and they have an impact on the surgical strategy. There are various surgical strategies for treatment of full-thickness macular holes depending on the size of the foramen and other biomarkers. The inverted ILM flap technique improves the closure rate of large macular holes. In lamellar macular holes showing signs of progression an early surgical intervention results in a good anatomical and functional prognosis.

CONCLUSION

Multimodal diagnostics provide important preoperative, intraoperative, and postoperative features for macular holes and lamellar macular holes, which are essential biomarkers for the exact classification, the therapeutic strategy and for assessment of the prognosis.

Inverted ILM Flap Technique in Idiopathic Full-Thickness Macular Hole Surgery: Functional Outcomes and Their Correlation with Morphologic Findings

Objectives

The inverted internal limiting membrane (ILM) flap technique has been shown to increase the success rate in large full-thickness macular holes (FTMHs) and in FTMHs associated with high myopia. The aim of our study was to confirm the efficacy and safety of inverted ILM flap technique in idiopathic FTMHs independent of their dimensions and to assess functional outcomes and their correlation to morphologic findings.

Methods

Sixteen consecutive patients affected by idiopathic FTMH were enrolled in this prospective study. The preoperative mean (±SD) diameter of the FTMH was 422 (±106) µm. All patients underwent vitrectomy and ILM peeling with inverted ILM flap. At 1-, 3-, and 6-month postoperative visits, visual acuity measurement, indirect ophthalmoscopy, and microperimetry were performed, and the foveal contour and the integrity of the ellipsoid zone (EZ) and external limiting membrane (ELM) were investigated using spectral domain optical coherence tomography (SD-OCT).

Results

At six months postoperatively, 15 out of 16 (93.75%) patients obtained FTMH closure. The mean best corrected visual acuity (BCVA) improved from 1.1 LogMAR to 0.3 LogMAR, and the mean retinal sensitivity (MS) improved from 7.2 to 23.4 dB. ELM defects were evident in 1 out of 16 (6.25%) eyes, and EZ defects were detected in 2 out of 16 (12,50%) eyes. A statistically significant relationship was observed between BCVA, MS, and EZ reconstitution at each follow-up visit.

Conclusions

Results confirm that the inverted ILM flap technique is a safe and effective option for FTMH treatment and show a strong correlation between higher BCVAs and MSs and EZ reconstitution after surgery.

The Influence of Crescent-Shaped Selective Internal Limiting Membrane Staining on Vital Dye Toxicity in Temporal Inverted Flap Technique

Purpose: To investigate the macular function and morphology after temporal inverted internal limiting membrane (ILM) flap technique with and without staining of the ILM flap in contact with the retinal pigment epithelium (RPE).Materials and Methods: This retrospective study included 30 patients with idiopathic macular hole (MH), who underwent 27 G vitrectomy and temporal inverted ILM flap technique with brillant blue G (BBG) assisted ILM staining. In Group 1 (n = 16), a large bubble of perfluorocarbon liquid (PFCL) measuring approximately 6-disc diameters was used to cover the hole and central part of the ILM flap whereas in Group 2 (n = 14), only a small drop of PFCL to merely cover the MH was used. Complete ophthalmic examination including microperimetry (MP), optical coherence tomography (OCT) was performed preoperatively, 6 months after surgery.Results: MH closure was achieved in all the eyes in both groups. The sizes of ellipsoid zone (EZ) and external limiting membrane (ELM) defect significantly decreased after surgery relative to the baseline width in both groups (p < .05 for all). The mean improvement in visual acuity (p = .896) and retinal sensitivity was similiar between groups (p = .409). Accordingly, the postoperative mean lengths of the EZ (p = .254) and ELM disruption (p = .406) on OCT scans were similiar between groups. However, 3 of the eyes in Group 2 developed cystoid macular edema between postoperative month-1 and month-6.Conclusion: The crescent-shaped selective staining of the ILM flap could prevent prolonged retinal toxicity of vital dyes in inverted ILM flap technique. Further studies involving larger number of patients with longer follow up are needed to determine the impact of this technique in the management of vital dye toxicity.

Efficacy of different doses of dye-assisted internal limiting membrane peeling in idiopathic macular hole: a systematic review and network meta-analysis

PURPOSE

Pars plana vitrectomy is the gold standard for the treatment of idiopathic macular hole. Several chromovitrectomy dyes have been used to improve the visualization of the internal limiting membrane (ILM), including indocyanine green, trypan blue (TB), brilliant blue G (BBG), and triamcinolone acetonide (TA). We conducted a network meta-analysis (NMA) to establish the optimum concentration of chromovitrectomy dye-assisted ILM peeling for IMH.

METHODS

We searched PubMed, Embase, and Cochrane Library for relevant studies before January 2020. We performed a random-effects NMA using STATA version 15.1 to assess mean difference and odds ratios with 95% confidence intervals.

RESULTS

We identified twelve retrospective trails and five randomized controlled trials (RCTs), comprising 1 492 patients of IMH on stage II-IV for ILM peeling. The results of IMH closure rate show that the effect of ILM peeling without dye was better than 0.25% ICG, the effects of ILM peeling with 0.5% ICG or TA were better than without dye, and the effects of ILM peeling with 0.05% BBG, 0.15% TB, 0.5% ICG or 0.05% ICG were better than 0.25% ICG. Ranking probability analysis shows that the rates of IMH closure after ILM peeling with 0.15% TB or 0.05% BBG were better than nine other concentrations of chromovitrectomy dyes.

CONCLUSION

The 0.15% TB and 0.05% BBG were recommended as the better efficient treatment-assisted ILM peeling for IMH closure. For retina specialists who prefer to use ICG to assist ILM peeling, 0.05% ICG may be a good choice. However, high-quality large-scale RCTs are recommended to confirm the NMA results.

INFLUENCE OF INVERTED INTERNAL LIMITING MEMBRANE FLAP TECHNIQUE ON THE OUTER RETINAL LAYER STRUCTURES AFTER A LARGE MACULAR HOLE SURGERY

PURPOSE

To examine the influence of inverted internal limiting membrane (ILM) flap technique on the outer retinal layer structures after macular hole (MH) surgery.

METHODS

We included 24 eyes of 24 patients who underwent vitrectomy for large MHs (≥400 µm) with successful MH closure and observed for at least 6 months. Fourteen eyes were treated with inverted ILM flap technique (inverted group) and 10 with conventional ILM peeling (ILMP group). We evaluated the postoperative recovery rate of the external limiting membrane and ellipsoid zone and the best-corrected visual acuity.

RESULTS

The postoperative recovery rates of the external limiting membrane and ellipsoid zone in the inverted group were lower than those in the ILMP group (21.4 vs. 70.0%, P = 0.024; 0 vs. 30.0, P = 0.059, respectively). The external limiting membrane recovery period in the inverted group was significantly longer than that in the ILMP group (11.0 ± 1.7 vs. 3.4 ± 2.8 months, P = 0.015). The best-corrected visual acuity change (letters) in the inverted group was significantly smaller than that in the ILMP group (9.0 vs. 22.5, P = 0.040).

CONCLUSION

The poorer anatomical and visual results associated with inverted ILM flap compared with ILM peeling suggest the limitation of the ILM flap technique to repair refractory MHs.

Inverted ILM-flap techniques variants for macular hole surgery: randomized clinical trial to compare retinal sensitivity and fixation stability

To report closure rate, Best Corrected Visual Acuity (BCVA), Retinal Sensitivity (RS) and Fixation Stability (FS) of idiopathic Macular Holes (MH) randomized to Cover Group (CG) or Fill Group (FG) of the Inverted Internal Limiting Membrane (ILM) flap surgical procedure. Twenty-eight patients were randomized (1:1) to receive a vitrectomy with either Cover or Fill ILM flap technique. All patients underwent BCVA, RS and FS assessment at baseline, 1-month and 3-months after surgery. MH closed in all patients. BCVA rose from 20/100 (baseline) to 20/33 (1-month) in both groups, to 20/28 in CG versus 20/33 in FG (3-months) (p < 0.05). The central 4° RS rose from 11.5 and 12 dB to 19 and 19.5 dB (1-month) and to 22 and 20 dB (3-months), respectively, in CG and FG (p < 0.001). The central 10° RS rose from 11 and 15 dB to 22 and 20 dB (1-month) and to 23 and 20 dB (3-months), respectively, in CG and FG (p < 0.001). FS increased significantly more in CG. CG improved significantly more than FG in terms of BCVA, RS and FS. The average MH diameter was relatively small (397 µm); larger MHs may behave differently.

Trial registration: Trial Registry: https://www.clinicaltrials.gov; Identifier: NCT04135638. Registration date 22/10/2019.

Central posterior lens capsule used instead of inverted ILM flap: a clinic-pathological case report

PURPOSE

To present immunocytochemical characterization of a surgically excised central posterior lens capsule (PLC) that was transplanted to close a secondary refractory full-thickness macular hole (FTMH) as an epiretinal flap. For comparison, tissue of both an unaffected internal limiting membrane (ILM) and unexposed PLC was processed.

METHODS

Clinical-pathological case report.

RESULTS

We report of a 38-year-old patient who underwent pars plana vitrectomy (PPV) with PLC tissue for patching secondary FTMH and silicone oil tamponade after tractional retinal detachment. The PLC was peeled off during a vitrectomy one year after positioning. For immunocytochemistry, the removed PLC was prepared as flat-mount and showed a positive immunofluorescence of the Müller cells marker glutamine synthetase (GS) and for vimentin. The microglia marker IBA and the neuroprotective neurotrophic marker glia cell-derived neurotrophic factor (GDNF) were tested positive, too. There was no immunoreactivity of cellular retinaldehyde-binding protein (CRALBP) and glial fibrillary acidic protein (GFAP). In comparison, tissue of a control ILM that was obtained during standard FTMH surgery showed few single cells that were likewise positive for GS, GDNF and IBA. The control specimen of unexposed PLC showed rarely cells that were without positive immunostaining for the tested markers.

CONCLUSION

Our analysis revealed positive immunoreactivity of macro- and microglia cells of PLC tissue that was used to patch a refractory FTMH. Similar immunostaining of PLC material and ILM suggests the PLC transplantation as an alternative treatment option for refractory FTMH.

Internal limiting membrane flap technique in macular hole surgery

Vitrectomy combined with internal limiting membrane (ILM) peeling is popular for the treatment of macular hole (MH). However, the improvements of MH closure rate and postoperative visual acuity are not satisfactory especially in large and refractory MHs. Currently, the ILM flap technique has gradually been applied for the treatment of MH and achieved high MH closure rate. The ILM flap technique has many variations, including the difference of the size, shape, number, and manner in which the flaps put on the MHs. The ILM flap technique also has some auxiliary means including perfluoro-n-octane (PFO), dye, autologous blood and adhesive viscoelastics. There is controversy about the effects between several technique variations of ILM flap, and it needs to be explored in the future.

Effects of inverted internal limiting membrane technique and insertion technique on outer retinal restoration associated with glial proliferation in large macular holes

PURPOSE

To compare the effects of inverted internal limiting membrane (ILM) flap technique and ILM insertion technique for large macular hole (MH) on glial proliferation, retinal outer layer restoration, and visual function.

METHODS

This retrospective, observational study included 25 eyes with large MH (minimum diameter, ≥ 400 μm) treated using the inverted ILM flap or insertion technique. The inverted flap group was defined as flipping the ILM upside down on the MH (13 eyes) and the insertion group as inserting multiple ILM layers into the MH (12 eyes).

RESULTS

Glial proliferation in the photoreceptor layer at 1 month and the final visit was significantly less frequent in the inverted flap group than in the insertion group (61.5% vs. 100%, p = 0.039; 23.1% vs. 100%, p = 0.001). The mean postoperative external limiting membrane defect was 140.4 ± 286.2 μm in the inverted flap group, significantly narrower than that in the insertion group (364.6 ± 181.6 μm; p = 0.016). The mean postoperative ellipsoid zone defect was 235.3 ± 214.2 μm in the inverted flap group, which was almost significantly narrower than that in the insertion group (496.3 ± 445.6 μm; p = 0.068). The change in the best-corrected visual acuity was significantly better in the inverted flap group than that in the insertion group (+ 18.5 vs. + 9.0 letters).

CONCLUSION

Compared with patients treated with the insertion technique, those treated with the inverted ILM flap technique had significantly less glial proliferation at the photoreceptor space, more preferable outer retinal formation, and better visual improvement.

ANATOMICAL AND VISUAL OUTCOMES OF INVERTED INTERNAL LIMITING MEMBRANE FLAP TECHNIQUE VERSUS INTERNAL LIMITING MEMBRANE PEELING IN MYOPIC MACULAR HOLE WITHOUT RETINAL DETACHMENT: A Preliminary Retrospective Study

PURPOSE

To compare the results of vitrectomy with internal limiting membrane (ILM) peeling and inverted ILM flap for treating myopic macular hole without retinal detachment.

METHODS

Twenty-eight eyes of 28 patients undergoing vitrectomy with either ILM peeling (n = 16) or inverted ILM flap technique (n = 12) were included. Outcomes were myopic macular hole closure by optical coherence tomography and visual acuity at 6 months and at the end of follow-up.

RESULTS

Closure of myopic macular hole was achieved in 13 eyes (81.2%) of the ILM peeling group and in 11 eyes (91.7%) of the inverted ILM flap group. The median length of follow-up was 18 months in the peeling group and 10.3 in the inverted group. There were not statistically significant differences between restoration of the external limiting membrane, external limiting membrane and ellipsoid zone, and none of both layers between the two groups. The median best-corrected visual acuity (logarithm of minimal angle of resolution) at the end of follow-up was 0.25 (20/35 Snellen) in the peeling group and 0.4 (20/50) in the inverted group (P = 0.027).

CONCLUSION

Both techniques were associated with high closure rates of myopic macular hole but the small sample size and the retrospective design prevents any claims of superiority of one technique over the other.

Infracyanine Green vs. Brilliant Blue G in Inverted Flap Surgery for Large Macular Holes: A Long-Term Swept-Source OCT Analysis

Background and Objectives: To compare the long-term toxicity of infracyanine green (IFCG) to brilliant blue G (BBG) in inverted internal limiting membrane flap surgery (I-ILMFS) for large, full-thickness macular holes (FTMHs). Materials and Methods: Prospective randomized study including 39 eyes with ≥ 400 µm idiopathic FTMH who underwent I-ILMFS with either IFCG or BBG. Postoperative 6- and 12-month corrected distance visual acuity (CDVA), closure rate, and swept-source optical coherence tomography parameters, including ellipsoid zone (EZ) and external limiting membrane (ELM) mean defect length, central foveal thicknesses (CFT), parafoveal macular thickness (MT), ganglion cells and inner plexiform layer (GCL++) thickness, and peripapillary nerve fiber layer (pRNFL) thickness, were compared. Results: Nineteen eyes were included in the IFCG group and 20 eyes in the BBG group. In all cases a FTMH closure was found. CDVA improved at 6 and 12 months in both groups (p < 0.0005); the increase at 12 months was greater in the BBG group (p = 0.036). EZ and ELM defects did not differ between groups at either follow-up time. CFT at 12 months was greater in the BBG group (p = 0.041). A 12-months compared to 6-months MT decrease was present in both groups (p < 0.01). The GCL++ superior inner sector was thicker in the BBG group at 12 months (p = 0.036), as were the superior outer sector (p = 0.039 and p = 0.027 at 6 and 12 months, respectively) and inferior outer sector (p = 0.011 and p = 0.009 at 6 and 12 months, respectively). Conclusion: In our study BBG in I-ILMFS exhibits better long-term CDVA and retinal thickness than does IFCG, suggesting a lesser toxicity from BBG. These findings support the use of BBG over IFCG in I-ILMFS.

Vitrectomy with internal limiting membrane peeling versus its flap insertion for macular hole in high myopia: a Meta-analysis

AIM

To compare the anatomic and functional outcomes between vitrectomy with internal limiting membrane (ILM) peeling and internal ILM flap insertion technique for high myopia macular hole (MH).

METHODS

PubMed, Cochrane Library, EMBASE, and CNKI were systematically searched, and all studies involved MH were included. The closure rate of MH and the postoperative best-corrected visual acuity (BCVA) at 6mo after the initial surgery were the primary measures. All statistical tests were performed in Review Manager 5.3.

RESULTS

Five studies that included 151 eyes of 151 patients were finally included, all of which were retrospectively comparative studies. Between the pars plana vitrectomy (PPV) with ILM peeling surgery and the ILM insertion technique, the latter had significantly better efficacy with respect to the closure rate of MH (OR=21.32, 95%CI=7.25-62.67, P<0.001); However, regarding BCVA at 6mo after the initial surgery in MH, there was no statistical significance between the groups (OR=-0.04, 95%CI=-0.22-0.14, P=0.66). In addition, regarding the rate of retinal reattachment after the initial surgery, the two different methods were not significantly different (OR=2.22, 95%CI=0.34-14.32, P=0.4).

CONCLUSION

Both ILM peeling and ILM insertion technique could significantly improve anatomic outcomes of MH in high myopia with or without retinal detachment (RD), and anatomic outcomes are more effective. However, there is no statistical significance in BCVA at 6mo after the initial surgery in MH, or in the rate of retinal reattachment after the first surgery, between the two methods.

Large Idiopathic Macular Hole Surgery: Remodelling of Outer Retinal Layers after Traditional Internal Limiting Membrane Peeling or Inverted Flap Technique

OBJECTIVE

To investigate the influence of the inverted flap technique compared with traditional internal limiting membrane (ILM) peeling in the postoperative remodelling of outer retinal layers of idiopathic macular holes (MHs) >450 µm.

METHODS

We analyzed medical records and imaging studies of all patients with an idiopathic MH >450 µm who underwent vitrectomy at the Sacco University Hospital, Milan, and the Sacro Cuore Don Calabria Hospital, Verona, Italy, between January 2008 and December 2017. Out of 41 eyes evaluated, 17 were treated with traditional ILM peeling and 24 with the inverted ILM flap technique. All patients underwent follow-up examinations every 3 months and all of them completed a final visit 12 months after surgery. Best-corrected visual acuity (BCVA) and optical coherence tomography (OCT) parameters were evaluated at each visit. The main outcome measures were the postoperative recovery rate of the external limiting membrane (ELM) and ellipsoid zone (EZ), and postoperative BCVA. Correlations between OCT measurements and visual outcome were analyzed.

RESULTS

The ELM recovery rate in the ILM peeling group (15/17 eyes, 88%) was higher than in the ILM flap group (14/24 eyes, 58%) (p = 0.079). The EZ recovery rate was similar in the 2 groups, 7/17 eyes (41%) in the ILM peeling and 8/24 eyes (33%) in the ILM flap group (p = 0.744). Eyes without a persistent hyper-reflective "plug" at the edges of the MH showed a significantly higher EZ recovery rate (11/18, 61%) compared with eyes showing a persistent plug (4/23, 17%) (p = 0.008). The mean BCVA improved significantly in both groups: from 0.93 logMAR (20/170) to 0.26 logMAR (20/36) in the ILM peeling and from 0.98 logMAR (20/190) to 0.37 logMAR (20/46) in the ILM flap group. The final BCVA tended to be better in the ILM peeling group (p = 0.085).

CONCLUSIONS

Given the limited information about the influence of ILM flap versus traditional ILM peeling in the postoperative remodelling of large idiopathic MHs, our data provides some new insights into the healing process of MHs >450 µm. This should be considered as part of the decision process about whether to perform an ILM flap in these patients.

Inverted internal limiting membrane flap technique versus complete internal limiting membrane peeling in large macular hole surgery: a comparative study

Background

To compare the anatomical and functional outcomes of the inverted internal limiting membrane (ILM) flap technique and the complete ILM removal in the treatment of large stage 4 macular hole (MH) > 400 μm and to evaluate reconstructive anatomical changes in foveal microstructure using spectral-domain optical coherence tomography.

Methods

This is a retrospective, consecutive, nonrandomized comparative study of patients affected by idiopathic, myopic or traumatic stage 4 MH (minimum diameter > 400 μm) treated with 25-gauge pars-plana vitrectomy with either complete ILM peeling (n = 23, Group 1) or inverted ILM flap technique (n = 23, Group 2), between August 2016 and August 2018. Main outcomes measured were the MH closure rate assessed by spectral-domain optical coherence tomography and the best-corrected visual acuity (BCVA) at six months. Foveal microstructure reconstructive changes were evaluated using SD-OCT to determine predictive factors of postoperative BCVA.

Results

Closure of MH was achieved in 16/23 cases of Group 1 (70%) and in 22/23 cases of the Group 2 (96%). Surgical failure was reported in 6 cases of Group 1 and 1 case of Group 2. The MH closure rate was significantly higher with the inverted ILM flap technique (P-value = 0.02). Average BCVA (LogMAR) changed from 1.04 ± 0.32 to 0.70 ± 0.31 in Group 1 and from 0.98 ± 0.22 to 0.45 ± 0.25 in Group 2 (P-value = 0.005) at 6 months. Improvement in BCVA (> 0.3 LogMAR units) was statistically higher in the Group 2 (P-value = 0.03). Restoration of foveal microstructure was significantly higher in the Group 2 at 6 months (52% vs 9%, P-value < 0.01). In Group 2, the integrity of the external limiting membrane at 3 months postoperatively was the only significant feature correlated with postoperative BCVA at 6 months (r = 0.562; P-Value = 0.01, forward stepwise regression analysis).

Conclusion

Inverted ILM flap technique is more effective than the classic ILM peeling for the closure of large stage 4 MHs > 400 μm, improving both anatomical and functional outcomes. Early recovery of the external limiting membrane at 3 months is a positive predictive value of postoperative BCVA 6 months after inverted ILM flap technique.

[Surgery of large and persistent macular holes]

Modern macular hole surgery results in high closure rates of over 90% and good functional results especially in macular holes up to 400 µm in diameter. The standard of care in most of these cases consists of transconjunctival sutureless pars plana vitrectomy, peeling of the inner limiting membrane (ILM) around the hole, followed by gas tamponade and positioning of the patient. As closure rates and functional results decrease with larger macular hole diameters over approximately 400 µm, alternative surgical techniques have been introduced to improve anatomical and functional results in these cases. These techniques include the positioning of tissue within the macular hole to improve hole closure. This can be performed using an ILM flap or free flap technique and the transplantation of autologous retinal tissue, lens capsule or homologous amniotic tissue in or under the defect. An alternative promising approach is the attenuation of the rim of the hole by induction of a localized retinal detachment at the posterior pole which is achieved by subretinal injection of balanced salt solution (BSS) using a 41 gauge needle. The operation is completed by an endotamponade using gas or silicone oil.

Folding the internal limiting membrane flap under perfluorocarbon liquid in large, chronic and myopic macular holes

PURPOSE

The purpose of the present paper is to describe a surgical technique aimed at creating multiple layers of Internal Limiting Membrane (ILM) using Perfluorocarbon Liquid (PFCL) in order to favour the closure of large, chronic and myopic Macular Holes (MH).

METHODS

Thirty patients belonging to 3 subgroups: large (> 500 μm), chronic (> 12 months) and myopic (> - 9 diopters), MHs, underwent surgery and completed 6 months follow-up. The ILM was engaged and peeled 360° around the MH, hinged to the rim and folded over the hole. A PFCL bubble spanning the vascular arcades was then injected and the ILM is grasped repeatedly to fold the distal edge towards the MH centre, creating multiple ILM layers over the MH.

RESULTS

MH closed in 26/30 cases (86.6%) with no significant difference among subgroups. Vision improved 2.57 ± 1.56 Snellen lines from LogMAR 1.50 ± 1.19 to 1.19 ± 1.32 (p < 0.01). Ellipsoid Zone (EZ) interruption width reduced from 1129 ± 439 μm to 258 ± 507 μm (p < 0.001) and correlated to pattern of MH closure, post-BCVA and line improvement (p < 0.001 in all cases).

DISCUSSION

The use PFCL allows multiple ILM layers and resulted in a high closure rate. Pattern of MH closure differs from those previously described leaving a plug of ILM tissue that interrupts retinal architecture often only in the inner layers. PFCL gravity and hydrophobicity displace aqueous while the intensely polar opposite faces of the ILM attract each other. The folded ILM plugs MH and bridges the gap and may help glial cell proliferation and migration.

[Vitrectomy and iOCT-assisted inverted ILM flap technique in patients with full thickness macular holes]

BACKGROUND

In large full thickness macular holes (FTMH) the closure rate after vitrectomy and conventional internal limiting membrane (ILM) peeling is less than 90%. The aim of this study was to examine the visual acuity and anatomical success rate with high-resolution optical coherence tomography (OCT) after transconjunctival sutureless 23-gauge pars plana vitrectomy as well as intraoperative OCT (iOCT) and Brilliant Peel (BP)-assisted ILM peeling using the inverted ILM flap technique in patients with large FTMHs.

METHOD

In this retrospective study 25 eyes of 25 consecutive patients with large FTMH were treated by 23-G vitrectomy with BP and iOCT-assisted ILM peeling using the inverted ILM flap technique followed by gas tamponade. In all patients best corrected visual acuity (BCVA) and the maximum diameter, base and height of the FTMH as well as intraretinal alterations were measured preoperatively using high-resolution spectral domain OCT (SD-OCT, Spectralis, Heidelberg Engineering, Germany). The BCVA was measured after 1, 3, and 6 months. Additionally, the closure rate and the microstructural integrity of the outer retinal layers, e.g. external limiting membrane (ELM), ellipsoid zone und photoreceptor outer segment (OS) were registered in the SD-OCT and correlated with the results of BCVA after macular hole surgery.

RESULTS

In all surgical procedures with the inverted ILM flap technique the application of iOCT enabled a good visualization and a controlled positioning of the ILM flaps. At baseline mean BCVA was 0.2 (0.7 logMAR) and improved significantly after 1, 3 und 6 months to 0.4 (0.4 logMAR), 0.5 (0.3 logMAR) and 0.63 (0.2 logMAR), respectively. The closure rate of the FTMHs was 100%. Microstructural integrity of the outer retinal layers was evaluated semiquantitatively and showed good correlation with BCVA.

CONCLUSION

Vitrectomy with BP and iOCT-assisted ILM peeling using the inverted ILM flap technique in patients with large FTMH is a very controlled and safe microsurgical strategy and shows good functional and anatomical results. The morphology of the FTMH, the ILM flap and the position of the inverted ILM flap under air was well visualized by IOCT. The microstructural integrity of the outer retinal layers is displayed in detail on SD-OCT and represents an important predictive parameter for BCVA after macular hole surgery.

A Technique for Closing Challenging Macular Holes

BACKGROUND AND OBJECTIVE

To describe a new technique for closing challenging macular holes (MHs).

PATIENTS AND METHODS

The technique involves vitrectomy with internal limiting membrane (ILM) peeling, isolating the macula under perfluorocarbon liquid, alternating scraping of the retina toward the MH, aspirating fluid from the MH until closure is achieved intraoperatively, and sealing the MH with an inverted ILM flap or autologous ILM free flap. Gas or oil tamponade is used to prevent rehydration of the MH.

RESULTS

Covering the MH with ILM scaffolding by the inverted flap technique or autologous ILM free flap promoted closure of large MHs by photoreceptor layer migration rather than gliosis. Iatrogenic macular trauma from manipulation produced funduscopic and optical coherence tomography changes but did not preclude significant vision improvement.

CONCLUSIONS

ILM scaffolding over the surgically reduced MH enhanced surgical closure by photoreceptor migration. Although anatomic success resulted in improvement in visual acuity, further study is required regarding long-term outcomes. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:450-452.].

Anatomical Changes of Full-Thickness Macular Hole Documented by Microscope-Integrated Spectral-Domain Optical Coherence Tomography

BACKGROUND AND OBJECTIVE

To evaluate anatomical changes of idiopathic macular hole (MH) after internal limiting membrane removal and after passive suction at the hole's borders using microscope-integrated intraoperative optical coherence tomography (iOCT).

PATIENTS AND METHODS

Five eyes of five subjects with full-thickness idiopathic MH underwent phacoemulsification, intraocular lens implantation, pars plana vitrectomy, and internal limiting membrane (ILM) removal. iOCT was performed after ILM removal and after passive suction at the hole's borders.

RESULTS

iOCT showed decreased MH diameter after ILM removal in all cases. Passive suction achieved complete apposition of borders. All cases presented successful postsurgical closure.

CONCLUSIONS

iOCT provides anatomical information during MH surgery that may impact surgical decision-making by allowing a real-time evaluation of structures. iOCT with preservative-free triamcinolone acetonide enhanced ILM visualization. Its use is superior to iOCT alone for the identification of vitreomacular interface structures. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:e105-e111.].

A Double Inverted Flap Surgical Technique for the Treatment of Idiopathic Lamellar Macular Hole Associated with Atypical Epiretinal Membrane

OBJECTIVES

To propose a new technique of a double inverted epiretinal membrane (ERM) and internal limiting membrane (ILM) flap (double flap group) for the treatment of idiopathic lamellar macular hole (LMH) with atypical ERM (AERM) and to compare surgical outcomes to those of the standard technique of ERM and ILM peeling of the fovea including LMH (control group).

METHODS

AERM was tomographically defined as a medium reflective thickened membrane above the retinal fiber layers without retinal traction signs. A series of patients affected by LMH with AERM were recruited. Preoperative parameters were: intraretinal cysts (IRC), intraretinal splitting diameter, residual foveal thickness, and ellipsoid zone integrity. Postoperative findings were: full-thickness macular hole (FTMH) development, and persistence or new appearance of IRC. Best-corrected visual acuity (BCVA) at baseline, first, third, and sixth postoperative month was evaluated.

RESULTS

A total of 48 eyes of 48 patients were included in this study. In the double flap group (30 eyes), a clear improvement of BCVA was noted (p = 0.004), and there were no complications. In the control group (18 eyes), BCVA did not improve and 3 patients developed postoperative FTMH.

CONCLUSIONS

The double inverted flap technique is associated with better functional recovery compared to the standard technique and reduces the risk of postoperative FTMH development.