A Modification of the Inverted Internal Limiting Membrane Flap Technique without Heavy Liquids and Prone Posturing

Abstract

Primary closure of large macular holes remains challenging, and variations of inverted inner limiting membrane (ILM) flap surgery have been described. In the present retrospective, interventional, single-centre case series, we propose a superior flap design with minimal posturing. Eight eyes of eight patients (four women and four men) in the period between July 2020 and March 2022 underwent 23 G three-port vitrectomy with a superior inverted ILM flap and 20% SF₆ endotamponade for a full thickness macular hole (MH) by the same experienced surgeon (F. M. H.). Seven MHs were classified as large (> 400 µm) and one as medium (250 – 400 µm). The mean MLD was 638.0 ± 166.4 µm (range: 353 – 851 µm). MH closure was achieved in all (8/8, 100%) patients with a single surgery. The median best-corrected visual acuity (BCVA) improved from 6/120 (Snellen) (range: finger counting [FC] to 6/19) preoperatively to 6/19 (range: FC to 6/9.5) after surgery, without any intra- or postoperative complications. The superior inverted ILM flap technique seems to be a safe and successful approach for the primary closure of large MHs. Further studies should investigate our proposed surgical technique on a larger population, potentially without air or gas endotamponade.

Key words

macular hole - vitreoretinal surgery - internal limiting membrane

Publication History

Received: 30 June 2022

Accepted: 19 October 2022

Article published online:
23 December 2022

• References/Literatur

• 1 Steel DH, Donachie PHJ, Aylward GW. et al. Factors affecting anatomical and visual outcome after macular hole surgery: findings from a large prospective UK cohort. Eye (Lond) 2021; 35: 316-325 DOI: 10.1038/s41433-020-0844-x.
• 2 Michalewska Z, Michalewski J, Adelman RA. et al. Inverted internal limiting membrane flap technique for large macular holes. Ophthalmology 2010; 117: 2018-2025 DOI: 10.1016/j.ophtha.2010.02.011.
• 3 Hess JA, Michels S, Becker MD. [Functional and Anatomic Outcomes of Primary and Secondary Internal Limiting Membrane Transplantation in Large and Persistent Macular Holes]. Klin Monbl Augenheilkd 2018; 235: 1159-1164 DOI: 10.1055/s-0043-121032.
• 4 Duker JS, Kaiser PK, Binder S. et al. The International Vitreomacular Traction Study Group Classification of Vitreomacular Adhesion, Traction, and Macular Hole. Ophthalmology 2013; 120: 2611-2619 DOI: 10.1016/j.ophtha.2013.07.042.
• 5 Michalewska Z, Michalewski J, Dulczewska-Cichecka K. et al. Temporal inverted Internal Limiting Membrane Flap Technique versus Classic Inverted Internal Limiting Membrane Flap Technique: A Comparative Study. Retina 2015; 35: 1844-1850 DOI: 10.1097/IAE.0000000000000555.
• 6 Ruparelia S, Tuli R, Park JSY. et al. Inverted Internal Limiting Membrane Flap Technique without Postoperative Face-Down Positioning for Macular Hole Repair. Retina 2022; 42: 548-552 DOI: 10.1097/IAE.0000000000003350.
• 7 Kannan NB, Kohli P, Parida H. et al. Comparative study of inverted internal limiting membrane (ILM) flap and ILM peeling technique in large macular holes: a randomized-control trial. BMC Ophthalmol 2018; 18: 177 DOI: 10.1186/s12886-018-0826-y.
• 8 Choi SR, Kang JW, Jeon JH. et al. The Efficacy of Superior Inverted Internal Limiting Membrane Flap Technique for the Treatment of Full-Thickness Macular Hole. Retina 2018; 38: 192-197 DOI: 10.1097/IAE.0000000000001619.
• 9 Stopa M, Ciesielski M, Rakowicz P. Macular Hole Closure Without Endotamponade Application. Retina 2020; DOI: 10.1097/IAE.0000000000002850.
• 10 Singh DV, Reddy RR, Sharma YR. et al. Epiretinal Membrane from Uncontrolled Gliosis After Inverted ILM Flap Technique for Idiopathic Macular Hole. Ophthalmic Surg Lasers Imaging Retina 2021; 52: 663-665 DOI: 10.3928/23258160-20211126-01.
• 11 Faria MY, Ferreira NP, Cristóvao DM. et al. Tomographic Structural Changes of Retinal Layers after Internal Limiting Membrane Peeling for Macular Hole Surgery. Ophthalmic Res 2018; 59: 24-29 DOI: 10.1159/000480243.