Inverted internal limiting membrane flap combined with subretinal viscoelastic injection for large or chronic macular holes

Abstract

PurposeTo report two cases with a large or chronic macular hole (MH) that was closed by combining the inverted internal limiting membrane (ILM) flap technique with the injection of ophthalmic viscoelastic device (OVD) into the subretinal space through the MH. ObservationsA 76-year-old woman was referred to our clinic for surgery of a MH with a maximum diameter of 1089 μm as determined by optical coherence tomography (OCT). Her visual acuity was 20/50 in the left eye after vitrectomy was performed at a local clinic to remove vitreous opacities. For our surgery, the ILM was peeled and the ILM flap was inverted and placed over the MH. Then, cohesive OVD was injected into the subretinal space through the MH to create a retinal detachment around the MH. The MH was closed by a gas tamponade, and the vision improved to 20/40. The second patient was a 62-year-old man whose vision had been decreasing for 3 years, and he was referred to our clinic. His vision was 20/40 in the left eye and OCT detected a MH with a maximum diameter of 853 μm. After core vitrectomy, the ILM was peeled, inverted, and placed over the MH. Then, dispersive and cohesive OVD was injected through the MH. During this procedure, the MH appeared to enlarge and elevate. Then a yellowish arch-shaped lesion appeared at the temporal edge of the macular detachment. The intraoperative OCT showed that the curled-up retinal pigment epithelium (RPE) within the temporal arch-shaped lesion was adherent to the outer retinal layer. Following gas tamponade, the MH was closed but the patient noticed a paracentric scotoma on the nasal side. The fundus autofluorescence (FAF) images showed a hypo-autofluorescent lesion corresponding to the RPE defect. At postoperative 4 months, his visual acuity had improved to 20/22 and the OCT image showed that the MH was closed with a recovery of the ellipsoid zone of the photoreceptors. The subjective paracentric scotoma disappeared, however the hypo-autofluorescent lesion persisted. Conclusions and ImportanceA combination of the inverted ILM flap and the subretinal injection of OVD can close a large or chronic MH. An RPE detachment caused by injecting OVD into the subretinal space should be avoided.