Microperimetric evaluation and predictive factors of visual recovery after successful inverted internal limiting membrane-flap technique for macular hole in high myopic eyes.

Introduction: Inverted Internal Limiting Membrane (ILM)-flap technique demonstrated its effectiveness, in terms of anatomical closure rate and visual acuity recovery for high myopic macular holes. We evaluated macular function after a successful inverted ILM-flap for macular holes in high myopic eyes (hMMH) using microperimetry to predict visual prognosis. Methods: A retrospective study on 23 eyes of 23 patients after surgical closure of hMMH, was performed. All patients underwent inverted ILM-flap and gas tamponade. Cataract surgery was performed in phakic eyes. Study outcomes including best-corrected visual acuity (BCVA), retinal sensitivity (RS) at central 12°, central retinal sensitivity (CRS) at central 4° and mean deviation (MD), and fixation behavior as bivariate contour ellipse area (BCEA, degrees2) measured by microperimetry, were evaluated over 6 months. A mixed-effects model was used to evaluate and compare the repeated measurements of outcomes between phakic and pseudophakic eyes. A regression model was performed to assess the relationship between BCVA at 6 months and independent variables. Results: Overall mean BCVA improved from 0.98 ± 0.21 logMAR at baseline to 0.47 ± 0.31 logMAR at the last follow-up (p < 0.001). Over 6 months, overall sensitivity measurements improved (RS, p = 0.001; CRS, p < 0.0001; MD, p = 0.03), and the BCEA decreased in dimension, although not significantly (p ≥ 0.05). The mixed model revealed a significantly better effect of inverted ILM-flap combined with cataract surgery on BCVA and CRS in phakic eyes than inverted ILM-flap alone in pseudophakic ones. The regression model revealed a relationship of 6-month BCVA with pre-operative BCVA (ß = 0.60, p = 0.02) and RS (ß = -0.03, p = 0.01). Conclusion: The inverted ILM-flap technique significantly improved visual acuity and retinal sensitivity after the hMMH closure, particularly when combined with cataract extraction. Pre-operative visual acuity and retinal sensitivity at central 12° may predict post-surgical visual acuity.

Impact of inverted internal limiting membrane-flap technique on functional outcome and structural restoration of small and medium size macular holes.

Purpose: To evaluate the impact of the inverted internal limiting membrane (ILM)-flap technique on the visual outcome and anatomical recovery for small (<250 µ), medium (<400 µ), and large (>400 µ) macular holes (MHs). Methods: Retrospective study included consecutive idiopathic MH cases operated on using the inverted ILM-flap technique. Clinical data were retrieved from electronic medical records (EMRs), surgical videos, and optical coherence tomography (OCT) machines. Eyes with axial length >25 mm, coexisting macular diseases, and follow-up <6 weeks were excluded. Data included the presence or absence of ILM flap and restoration of External Limiting Membrane (ELM), Ellipsoid Zone (EZ) lines. Mean visual improvement and structural recovery were compared between eyes showing ILM flap and those showing no flap in three MH size groups. Results: Forty eyes of 38 patients with a mean age of 62.7 ± 10.1 years and a mean MH diameter of 348 ± 152 µm were included. The mean follow-up was 527 ± 478 days with anatomical closure observed in all eyes. Mean best-corrected visual acuity (BCVA) improved significantly from 0.87 ± 0.38 to 0.35 ± 0.26. ILM flap was visible in 29 (72.5%) all MHs, 7 (53.8%) small MHs (n = 13), 8 (61.5%) medium MHs (n = 13), and 14 (100%) large MHs (n = 14). The mean BCVA change was 0.47 ± 0.34, 0.53 ± 0.48, and 0.56 ± 0.20 in large, medium, and small MHs, respectively, and the difference between eyes showing ILM flap versus no flap in each MH size group was not statistically significant (P > 0.05). However, for medium MHs, it was higher in the ILM flap (0.66 ± 0.52) group compared to the no flap (0.32 ± 0.37) group. One eye with small MH developed significant gliosis resulting in reduced BCVA. ELM was restored in all eyes with small and medium MHs. Conclusion: We observed that the ILM flap did not adversely affect anatomical and visual outcomes for MHs <400 µm. Restoration of ELM suggests minimal interference in structural recovery by an ILM flap.

Full-Thickness Macular Hole in Coats Disease Treated Using the Inverted Internal Limiting Flap Technique.

Purpose: To report vitrectomy with the inverted internal limiting membrane (ILM) flap technique in a patient with a full-thickness macular hole (FTMH) and Coats disease. Methods: A case and its long-term findings were analyzed. Results: A 27-year-old patient with Coats disease who was treated 5 years earlier with laser photocoagulation presented with an FTMH. Vitrectomy with the temporal inverted ILM flap technique was performed. The macular hole decreased in size on serial OCT scans but did completely close until 18 months postoperatively. The final visual acuity was 20/40 (0.3 logMAR). The patient's vision remained stable for the next 5 years. Conclusions: Although the healing process after vitrectomy with ILM peeling and the inverted flap technique in an FTMH coexisting with Coats disease is prolonged compared with an idiopathic FTMH, it is still possible to obtain satisfactory anatomic and functional results.

The effect comparison of ILM flap and traditional ILM peeling in iMH.

Purpose: To compare the changes in anatomical structure and visual function after idiopathic macular hole (iMH) treatment with internal limiting membrane (ILM) peeling and inverted ILM flap and determine the value of the inverted ILM flap for the treatment of iMH. Methods: Forty-nine patients with iMH (49 eyes) were included in this study and followed up for 1 year (12 months) after treatment with inverted ILM flap and ILM peeling respectively. The main foveal parameters assessed included the preoperative minimum diameter (MD), intraoperative residual fragments, and postoperative ELM reconstruction. Visual function was assessed using best-corrected visual acuity. Results: The hole closure rate was 100% for 49 patients; 15 patients were treated with the inverted ILM flap, and 34 patients underwent ILM peeling. There were no differences between the postoperative best-corrected visual acuities and the rates of ELM reconstruction for the flap and peeling groups with different MDs. In the flap group, ELM reconstruction was associated with the preoperative MD, presence of an ILM flap, and hyperreflective changes in the inner retina 1 month after surgery. In the peeling group, ELM reconstruction was associated with the preoperative MD, intraoperative residual fragments at the hole edge, and hyperreflective changes in the inner retina. Conclusion: The inverted ILM flap and the ILM Peeling were both able to obtain high closure rate. However, the inverted ILM flap showed no obvious advantages related to anatomical morphology and visual function over ILM peeling.

Modified inverted internal limiting membrane flap technique for macular hole closure.

PURPOSE: To investigate the efficacy of modified internal limiting membrane (ILM) flap technique combined with vitreous surgery for treating macular holes and examine the outcomes in visual function and anatomic macular hole closure. STUDY DESIGN: Retrospective, observational. METHODS: Between July 1, 2015, and October 1, 2019, the modified inverted ILM flap technique combined with vitreous surgery was used to treat idiopathic macular holes, postoperative progression was then followed for at least 6 months in 96 participants (98 eyes). We modified the method by removing the lower half of the ILM while peeling and inverting the upper half. The mean age of the participants was 65.9 ± 11.9 years (41 men (42.7%) and 55 women (57.3%)). Retrospective evaluations of macular hole diameter, corrected visual acuity, and macular hole closure rates were performed using data from medical records. RESULTS: The mean macular hole diameter was 623.6 ± 207.4 µm. The mean corrected visual acuity (logMAR) was 0.79 ± 0.27 before surgery and 0.46 ± 0.35 at 1, 0.35 ± 0.39 at 3, and 0.31 ± 0.36 at 6 months Post surgery, showing significant differences before and after surgery (p = 2.30 × 10- 2). The macular hole closure rate was 98%. CONCLUSION: The modified inverted ILM flap technique combined with vitreous surgery was an effective method for treating macular holes, resulting in improvement in closure and visual acuity.

Outcomes of Vitrectomy with Fovea-Sparing and Inverted ILM Flap Technique for Myopic Foveoschisis.

Surgical treatment of myopic foveoschisis (MF) can result in a macular hole in 11−17% of patients that may lead to poor visual outcomes and progression to macular hole retinal detachment. We evaluated the benefit of vitrectomy to treat MF using the inverted internal limiting membrane (ILM) flap and fovea-sparing ILM techniques. We studied 20 eyes of 20 patients (7 men, 13 women) with high MF (mean axial length, 29.3 ± 1.7 mm). MF was classified by optical coherence tomography findings: retinoschisis (7 eyes) or foveal detachment (13 eyes). Between October 2013 and June 2021, we performed vitreous surgery in all 20 patients, employing both techniques. Air tamponade was used in 4 eyes, SF6 gas in 10 eyes, and C3F8 gas in 6 eyes. All patients stayed in the face-down position for one full day postoperatively. Visual acuity and foveal contour were analyzed using optical coherence tomography before surgery and at 3 and 6 months postoperatively. LogMAR visual acuity was 0.46 before surgery, with a significant improvement at 3 months (0.34) and at 6 months (0.2) postoperatively (p = 0.024, p < 0.001, respectively). In all patients, the foveal contour showed improvement without macular hole formation after surgery. These results show that vitrectomy, performed using the inverted ILM flap and fovea-sparing ILM technique, is effective for treating MF.

360° inverted internal limiting membrane flap technique for idiopathic macular holes ≤ 250 µm, > 250 and ≤ 400 µm, and > 400 µm.

PURPOSE: To study the functional and morphological results of the inverted internal limiting membrane (ILM) flap technique for the treatment of idiopathic macular holes (MHs) sized ≤ 250 µm, > 250 and ≤ 400 µm, and > 400 µm. METHODS: Retrospective, nonrandomized interventional study of 65 eyes with primary idiopathic MHs who underwent pars plana vitrectomy (PPV) with the inverted ILM flap technique. Closure rate, best-corrected visual acuity (BCVA), and integrity of external limiting membrane (ELM) and ellipsoid zone (EZ) were analyzed by optical coherence tomography (OCT). RESULTS: Total closure rate was 96.9% with 100% in the ≤ 250 µm group, 100% in the > 250 and ≤ 400 µm group, and 91.7% in the > 400 µm group. Mean BCVA significantly improved after treatment: from 0.7 to 0.3 LogMAR in the ≤ 250 µm group (n = 15, p < 0.001), from 0.9 to 0.4 LogMAR in the > 250 and ≤ 400 µm group (n = 26, p < 0.001), and from 1.0 to 0.5 LogMAR in the > 400 µm group (n = 24, p < 0.001). A total of 16 patients had follow-up over 14 months: BCVA increased from 0.9 LogMAR preoperatively to 0.4 after 1 month (p < 0.00001) and to 0.3 LogMAR after 14 months (p = 0.03). A recovered ELM could be observed in 56.3% after 1 month and in 87.5% after 14 months. A recovered EZ could be observed in 18.8% after 1 month and in 68.8% after 14 months. CONCLUSION: The study demonstrates a high closure rate with corresponding restitution of outer retinal layers. In addition to its importance for the treatment of MHs > 400 µm, the inverted ILM flap technique also appears to be effective and safe for the treatment of MHs < 400 µm. TRIAL REGISTRATION: WHO: DRKS00021241.

Vitrectomy for full thickness macular hole developed during the course of anti-VEGF treatment of type 1 neovascular AMD.

PURPOSE: To report a case of treatment of a full-thickness macular hole, which appeared after 10 months of anti-VEGF treatment in neovascular age related macular degeneration (nAMD). METHODS: The patient was diagnosed as type 1 nAMD. The coexisting vitreomacular traction caused a full thickness macular hole after 10 months of treatment. PATIENTS: A 68-year-old woman treated with anti VEGF. RESULTS: Vitrectomy with the temporal inverted ILM flap technique succeeded in closing the hole. Further anti-VEGF treatment followed. CONCLUSION: FTMH is a rare complication or coexistence in nAMD. Vitrectomy and continuous anti-VEGF treatment might result in satisfactory anatomical and functional results.

Combination of Inverted ILM Flap Technique and Subretinal Fluid Application Technique for Treatment of Chronic, Persistent and Large Macular Holes.

INTRODUCTION: The choice of surgical treatment for chronic, persistent and large full-thickness macular holes (FTMH) continues to be undefined and challenging, as some of these cases remain refractory to the treatment. We report the efficacy of combination of inverted internal limiting membrane flap technique (IILMFT) and subretinal application of the fluid (SR fluid application) technique for treatment of refractory FTMHs. METHODS: Nine patients (nine eyes) were enrolled into this retrospective non-randomized exploratory consecutive case series study. All patients were diagnosed with chronic, persistent or large FTMH and were treated with a combination of IILMFT and SR fluid application technique. The following outcome parameters were analysed during 1- and 6-month follow-up visits: anatomical FTMH closure rate on spectral domain optical coherence tomography (SD-OCT), best-corrected visual acuity (BCVA), degree of postoperative retinal displacement. RESULTS: The mean preoperative diameter of FTMH was 542.0 µm (range 154-1930 µm). Final closure of FTMH was achieved in nine of nine cases (100%). In one case a second operation was required because of postoperative rhegmatogenous retinal detachment. The mean BCVA after the FTMH closure increased from 1.0 logMAR (0.7-1.3) to 0.4 logMAR (0.2-0.8 logMAR) (W = 2.67; p = 0.008). A positive correlation was revealed between preoperative BCVA and axial length (ρ = 0.67, p = 0.048), between preoperative BCVA and duration of the symptoms (ρ = 0.818, p = 0.007), as well as between postoperative BCVA at 1-month follow-up and BCVA at 6-month follow-up (ρ = 0.821, p = 0.007). CONCLUSION: Combination of IILMFT with SR fluid application technique for refractory FTMH surgery appears to be effective and safe. Improvement of anatomical and visual outcomes after the single surgery benefits from and is ensured by the advantages of both novel surgical approaches.

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.

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.

Fovea Morphology After Vitrectomy in Eyes With Full-Thickness Macular Hole Coexisting With Diabetic Retinopathy.

Purpose: This work presents the effects of vitrectomy with an inverted internal limiting membrane flap in full-thickness macular holes (FTMHs) in eyes with diabetic retinopathy (DR). Methods: Vitrectomy with the inverted and temporal inverted internal limiting membrane flap technique was performed in all cases. Inclusion criteria were FTMH, diabetes treated with oral drugs or with insulin for at least 5 years, spectral-domain or swept-source optical coherence tomography performed before surgery then 1 week, 1, 3, 6, 12, and 18 to 36 months after surgery. Results: FTMH with nonproliferative DR (NPDR) was noted in 20 eyes and with proliferative DR (PDR) in 5 eyes. In PDR the margins of the macular holes (MHs) were always detached, and the MHs tended to be larger than in NPDR. The minimum diameter-to-base diameter ratio was 1:2 in NPDR and 1:10 in PDR. Postoperatively central retinal thickness and visual acuity (VA) were significantly lower for PDR. Twenty-one of 25 FTMHs were closed after the first surgery, and all were closed after the second surgery. VA improved, final results did not depend on FTMH diameter. Photoreceptor defects decreased in size but were present in all cases 12 months after surgery. Conclusions: Morphology of MHs in NPDR and PDR was varied. FTMH in NPDR resembled idiopathic cases; morphology of FTMH with PDR was different. In PDR, FTMHs were larger and the fovea was usually detached; retina thinning was also observed. Final VA depended on initial VA and the severity of the disease (NPDR vs PDR).

The Pigtail Sign: A New Spectral Domain Optical Coherence Tomography Finding After Inverted ILM Flap Surgery for Idiopathic Macular Hole.

PURPOSE: To report a new spectral domain optical coherence tomography (OCT) finding called the pigtail sign. It was found during follow-up of idiopathic macular hole cases after inverted internal limiting membrane (ILM) flap surgery. METHODS: This is a retrospective case series of 12 eyes (12 patients) who underwent inverted ILM flap technique for idiopathic macular hole closure. Spectral domain optical coherence tomography images were analyzed for the presence of this new finding. RESULTS: A new spectral domain OCT finding of a curved coiled line hanging above the surface of the retinal layers was seen in all patients. The mean preoperative best corrected visual acuity (BCVA) logMAR value was 1.25 ± 0.11. At the 6-month follow-up visit, the mean LogMAR BCVA was 0.35 ± 0.18. All the cases showed macular hole closure after surgery. CONCLUSION: This new spectral domain OCT sign can be seen in some OCT scans during follow-up of idiopathic macular hole cases after inverted ILM flap surgery.

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.

Inverted internal limiting membrane-flap technique for large macular hole: a microperimetric study.

BACKGROUND: Inverted Internal Limiting Membrane (ILM)-flap technique would seem to lead to higher closure rate and better visual acuity than traditional procedure with ILM peeling for the treatment of large macular hole (LMH). Visual acuity recovery does not reveal many other functional changes related to surgical approach. Our purpose was to evaluate macular function and morphology over a 1-year follow-up after inverted ILM-flap technique for LMH by using microperimetry in order to predict visual prognosis. METHODS: This study was a prospective unrandomized single-center study. 23 eyes of 22 patients with idiopathic LMH, with a minimum diameter ranging from 400 to 1000 µm, were included. All patients underwent vitrectomy with inverted ILM-flap technique and gas tamponade. We analyzed macular hole closure rate and functional outcomes including best-corrected visual acuity (BCVA), macular sensitivity (MS) at central 12° and central macular sensitivity (CMS) at central 4°, and fixation behavior as bivariate contour ellipse area (BCEA, degrees2) at 68%, 95%, and 99% of fixation points measured by microperimeter, over a follow-up of 12 months. RESULTS: The macular hole closure rate was 98%. The BCVA improved from 20/230 (Logmar, 1.06 ± 0.34) to 20/59 (logMar, 0.47 ± 0.45) at last follow-up (p < 0.001). Retinal sensitivity and BCEA significantly improved (MS, p = 0.001; CMS, p < 0.0001; BCEA: 68%, p < 0.01; 95%, p < 0.01; 99%, p = 0.001). Multiple stepwise regression analysis showed the final BCVA was significantly associated with macular hole size (ß = 0.002, p = 0.03), preoperative MS (ß = - 0.06, p = 0.001) and BCEA at 95% and 99% of fixation points (ß = - 0.12, p = 0.01; ß = 0.06, p = 0.01). CONCLUSIONS: Inverted ILM-flap technique for LMH results in good morphologic and functional outcomes. Macular hole size and microperimetric parameters as preoperative MS and BCEA have a predictive role on post-surgical visual acuity.

Prevalence of Closure of Large Macular Hole with Inverted Internal Limiting Membrane Flap Technique in A Tertiary Care Hospital of Nepal.

INTRODUCTION: Large macular holes cause significant reduction in central visual acuity. The aim of the study is to find out short term anatomical and visual outcomes of inverted internal limiting membrane flaps technique for large macular holes (base diameter>1000µm) surgery in patients at a tertiary care hospital. METHODS: A descriptive cross-sectional study was conducted in a tertiary care hospital from January 2018 to December 2018 after ethical clearance from the institutional review committee. The study was done in 12 patients with idiopathic macular holes (base diameter>1000µm), they were repaired with 25 gauge pars plana vitrectomy with brilliant blue assisted large inverted internal limiting membrane flap technique. Statistical analyses were performed using SPSS 19.0 Results: All twelve eyes had complete anatomical closure. Mean best corrected visual acuity preoperatively was 1.48 logMAR±0.246. The mean macular hole base diameter was 1217.0±196.77µm. The mean age of patients was 68.75±4.97 years. Postoperatively, mean best corrected visual acuity was 0.978 logMAR±0.12. There were no postoperative complications. All the patients perceived decreased size of central scotoma. CONCLUSIONS: Inverted internal limiting membrane flaps for large macular holes is suitable method for closure of the very large hole, restoration of functional vision and decreased size of central scotoma.

[Vitrectomy and iOCT-assisted inverted ILM flap technique in patients with full thickness macular holes]. / Vitrektomie mit iOCT-assistierter invertierter ILM-Flap-Technik bei großen Makulaforamina.

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.

Comparative study of inverted internal limiting membrane (ILM) flap and ILM peeling technique in large macular holes: a randomized-control trial.

BACKGROUND: The anatomical success rate of macular hole surgery ranges around 93-98%. However, the prognosis of large macular holes is generally poor. The study was conducted to compare the anatomical and visual outcomes of Internal Limiting Membrane (ILM) peeling vis-a-vis inverted ILM flap for the treatment of idiopathic large Full-Thickness Macular Holes (FTMH). METHODS: This was a prospective randomized control trial. The study included patients with idiopathic FTMH, with a minimum diameter ranging from 600 to 1500 µm. The patients were randomized into Group A (ILM peeling) and Group B (inverted ILM flap). The main outcome measures were anatomical and visual outcome at the end of 6 months. Anatomical success was defined as flattening of macular hole with resolution of the subretinal cuff of fluid and neurosensory retina completely covering the fovea. RESULTS: There were 30 patients in each group. The mean minimum diameters in Group A and B were 759.97 ± 85.01 µm and 803.33 ± 120.65 µm respectively (p = 0.113). The mean base diameter in group A and B was 1304.50 ± 191.59 µm and 1395.17 ± 240.56 µm respectively (p = 0.112). The anatomical success rates achieved in Group A and B were 70.0 and 90.0% respectively (p = 0.125). The mean best-corrected visual acuity (BCVA) after 6 months was logMAR 0.65 ± 0.25 (Snellen equivalent, 20/89) in Group A and logMAR 0.53 ± 0.20 (Snellen equivalent, 20/68) in Group B (p = 0.060). The mean improvement in BCVA was 1.4 lines and 2.1 lines in groups A and B respectively (p = 0.353). BCVA≥20/60 was achieved by 13.3 and 20.0% in group A and B respectively (p = 0.766). CONCLUSION: The anatomical and functional outcome of Inverted ILM flap technique in large FTMH is statistically similar to that seen in conventional ILM peeling. TRIAL REGISTRATION: Clinical Trials Registry - India (Indian Medical Research) CTRI/2017/11/010474 .

Clinical and histological evaluation of large macular hole surgery using the inverted internal limiting membrane flap technique.

PURPOSE: The aims of this study were to analyze optical coherence tomography (OCT) imaging of large macular holes (MHs) treated with inverted internal limiting membrane (ILM) flap technique and to perform a histological examination of an ILM-like membrane tissue obtained during vitrectomy. PATIENTS AND METHODS: This is a retrospective observational case study. Nine patients, comprising of five males and four females, showing large and myopic MHs, underwent pars plana vitrectomy (PPV) with inverted ILM flap technique assisted by brilliant blue G (BBG) staining. Ophthalmological findings including visual acuity and OCT were investigated based on medical records. Formalin-fixed paraffin-embedded tissue section of an ILM-like membrane was submitted for immunohistochemistry with glial fibrillary acidic protein (GFAP). RESULTS: ILM was clearly stained with BBG in eight patients, whereas the ILM in one case revealed no staining with BBG during PPV. Visual acuities improved to >0.2 LogMAR in six patients. The complete closure of MH following PPV with inverted ILM technique was eventually achieved in all patients determined by OCT imaging (100%). Only one patient showed recovery of ellipsoid zone and interdigitation zone following the surgery. Elongation of outer nuclear layer was noted in three eyes. The ILM-like membrane not stained with BBG histologically revealed an amorphous structure admixed with GFAP-positive mononuclear cell infiltration. CONCLUSION: PPV with inverted ILM flap technique achieved 100% closure rates with favorable configuration at an initial surgery in large MHs. Our histopathological data also suggest that even BBG staining-negative membrane may be a useful material for autologous transplantation to the hole.

Macular hole surgery in a patient who cannot maintain facedown positioning.

AIM: To present macular hole surgery in a patient who had previously undergone thyroid removal surgery. MATERIAL AND METHODS: During thyroid gland removal surgery, the recurrent laryngeal nerves were cut by the surgeon. Therefore, the patient had to have a tracheotomy and because of this unusual situation, the patient could not breathe if lying 'upside-down'. Complete ophthalmic examination and spectral optical coherence tomography was performed in a 77-year-old woman before and after macular hole surgery. RESULTS: The patient was treated by the 'inverted internal limiting membrane (ILM) flap technique' with air tamponade for macular hole closure. This technique was described to have very high success rates in large, stage IV macular holes. Postoperatively, lying on her opposite side was advised. However, the macular hole remained open after this approach. Because of this, another approach was undertaken. The ILM flap technique and silicone oil were applied, and the patient was positioned on her opposite side. Silicone oil was removed after 3 months. Eighteen months later, the macular hole remained closed. Visual acuity improved from 10/200 to 20/50. CONCLUSION: This case demonstrates that in an extremely select group of patients, silicone oil combined with the inverted flap technique may be considered for treatment of macular hole.