Postoperative Dynamics of Full-Thickness Macular Holes: Insights from High-Resolution OCT Under Gas Tamponade.

To compare the anatomical and functional outcomes of the inverted internal limiting membrane(ILM) flap technique and ILM insertion technique for the treatment of large macular holes(MHs). Seventy-four consecutive eyes with large MHs(minimum diameter ≥400 µm) were included. All patients underwent 25-gauge pars plana vitrectomy(PPV) with either inverted ILM flap technique(n=40) or ILM insertion technique(n=34). Swept source optical coherence tomography (SS-OCT) was performed before surgery and 12 months postoperatively. The rate of MH closure, postoperative best corrected visual acuity(BCVA) and SS-OCT findings were evaluated at 12 months after surgery. MH closure was achieved in 34 eyes(85%) of the inverted ILM flap group and in 30 eyes(88.2%) of the ILM insertion group.There was no significant difference in the rate of MH closure(P=0.685). The mean BCVA improved from 1.30±0.81 logMAR (Snellen: 20/400) at baseline to 0.64±0.67 logMAR (Snellen: 20/87) at 12 months in the inverted ILM flap group, which was significanlty better than that in the insertion ILM group(P=0.047). At 12 months, the mean external limiting membrane (ELM) defect sizes was 106.68±196.25 µm in the inverted ILM flap group and 234.12±296.06 µm in the ILM insertion group, whereas the mean ellipsoid zone (EZ) defect sizes were 167.08±223.08 µm and 261.58±290.92 µm, respectively. The mean ELM defect sizes were significantly smaller in the inverted ILM flap group than in the ILM insertion group(p=0.039). However, there was no significant difference in mean EZ defect sizes between the two groups(P=0.160). Both the inverted ILM flap and the insertion ILM techniques were associated with high rates of MH closure in large MHs. The inverted ILM flap technique seemed to be more effective surgery for large MHs compared with the ILM insertion techniques in improving visual outcomes.

Inverted Internal Limiting Membrane Flap versus Internal Limiting Membrane Peeling for Macular Hole Retinal Detachment in High Myopia

PurposeThe aim of this study was to determine the effect of the inverted internal limiting membrane (ILM) flap technique on the macular hole (MH) closure and foveal microstructure recovery of...

Objective To observe the clinical efficacy of vitrectomy combined with modified inverted internal limiting membrane (ILM) flap covering technique for complicated macular hole (MH). Methods This is a retrospective case series. Twenty-one eyes of 20 patients who underwent vitrectomy combined with modified inverted ILM flap covering technique were enrolled in this study. Among these eyes, 9 eyes were idiopathic MH (IMH), with the mean basal diameter of (1 188.3±155.1) μm, minimum diameter of (626.9±86.2) μm, logarithm of the minimum angle of resolution (logMAR) best corrected visual acuity (BCVA) of 1.1±0.3; 2 eyes were MH with high myopia, with the mean basal diameter of (696.5±232.6) μm, minimum diameter of (259.0±69.3) μm, logMAR BCVA of 1.3; 5 eyes were high myopia MH with retinal detachment (RD), with the mean BCVA of 1.5±0.1; 3 eyes were rhegmatogenous RD (RRD) with MH, with the mean logMAR BCVA of 1.6; 2 eyes were MH after vitrectomy for RRD, with the mean basal diameter of (1 606.0±69.3) μm, minimum diameter of (909.0±387.5) μm, logMAR BCVA of 1.6. All patients received 23G or 25G vitrectomy after removal of posterior vitreous cortex intraoperatively. Indocyanine green staining assisted circle-wise ILM peeling was performed. ILM of diameter 1.5 disc-diameters around fovea was residual and loosened; perfluoronoctane assisted inverting superior or temporal residual ILM covering on macular hole. C3F8, gas or silicone oil tamponade was performed at the end. BCVA and hole closure were followed up for 1-4 months. C3F8, gas or silicone oil was tamponaded at the end. BCVA and hole closure were followed up for 1-4 months. Results MH of 21 eyes were closed after surgery. Nine IMH were closed at typeⅠ, with U shape closure in 7 eyes, V shape closure in 2 eyes. Two eyes of MH with high myopia, 3 eyes of RRD with MH, 2 eyes of MH after vitrectomy for RRD were closed at typeⅠ of U shape. Five eyes of high myopia MHRD including MH closure at typeⅠ of U shape 3 eyes, typeⅡ of W shape 2 eyes. The mean logMAR BCVA of IMH, MH with high myopia, high myopia MHRD, RRD with MH, MH after vitrectomy for RRD eyes were 0.8±0.3, 0.9±0.2, 1.4±0.1, 0.7±0.3, 0.9±0.2, respectively. The mean postoperative logMAR BCVA in IMH eyes was improved compared preoperative one (P=0.02). There was no obvious change of pre-and postoperative logMAR BCVA in MH with high myopia, high myopia MHRD, RRD with MH, MH after vitrectomy for RRD eyes (P=0.18, 0.10, 0.11, 0.18). Conclusion Vitrectomy combined with inverted ILM flap covering technique for complicated MH is an effective method to improve the success rate of MH closure and the visual function. Key words: Retinal Perforations/surgery; Vitrectomy

PurposeTo evaluate the efficacy of the inverted internal limiting membrane (ILM) flap technique in vitrectomy for macular hole (MH) with retinal detachment (RD) compared with vitrectomy using ILM peeling.MethodsA retrospective case series study was performed. Twenty-two eyes of 22 patients who underwent vitrectomy for MH with RD and followed-up more than 12 months after the surgery were included in this study. We retrospectively reviewed the medical records of patients who underwent vitrectomy with inverted ILM flap technique or vitrectomy with ILM peeling. Ten patients who had been treated vitrectomy with inverted ILM flap technique, and 12 patients who had been treated vitrectomy with ILM peeling were analyzed. We evaluated changes in best-corrected visual acuity (BCVA) before and after surgery, closing rates of MH, and retinal reattachment rates and compared between both groups.ResultsMH was closed and RD was reattached postoperatively in 9 eyes (90%) in the inverted ILM flap group. In the ILM peeling group, the MH was closed in 4 eyes (33.3%) and the retinas were reattached in 6 eyes (50%) after surgery. Significant improvement in BCVA after surgery (P = 0.0017) was only found in the inverted ILM flap group.ConclusionsHigher rates of closed MH and retinal reattachment, and small but significant improvement in BCVA were found in the inverted ILM flap group. Based on our data, the inverted ILM flap technique may be useful in vitrectomy for MH with RD.

Large macular holes are not uncommon among Nepalese women population causing severe visual problem. To evaluate the technique of inverted internal limiting membrane (ILM) flaps for the repairment of large macular holes. All 10 macular holes (diameter > 400 μm) were treated with pars planavitrectomy with inverted ILM flap technique. The procedure for macular hole surgerywas pars plana vitrectomy, posterior vitreous removal, internal limiting membrane(ILM) peeling with brilliant blue assisted, inverting ILM flap into macular hole, filling of the vitreous cavity with a gas bubble(C3 F8) and post-operative face-down positioning for 1 week. SD OCT images were taken preoperative and postoperative 1 month and 3 months follow up to assess the anatomical outcome of surgery and best corrected visual acuity (BCVA) was used to evaluate the functional outcome during each visit. The BCVA was recorded using the Snellen chart and was converted to the logarithm of the minimum angle of resolution (LogMAR) equivalents. All 10 eyes had complete anatomical closure. The mean age of patients was 64.3 ± 7.53 years. The mean macular hole base diameter was 1039.4 μm (663-1526μm). Mean BVCA pre-operatively was 1.29 log MAR ±SD 0.25. Post-operatively, mean BCVA was 0.925 log MAR ±SD 0.143 (p= 0.002). There were no intra operative or post-operative complications. All the patients were followed up for a period of 3months. Inverted ILM flaps is effective for closure of the large macular hole and restoration of functional vision.

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.

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.

Purpose: To report a case of the expansion of submacular retinal pigment epithelium (RPE) atrophy after using the inverted internal limiting membrane (ILM) flap technique for a persisting, large, stage IV macular hole (MH). Case Report: A 79-year-old woman presented with a chronic large MH that remained open despite pars plana vitrectomy (PPV). The surgery was performed twice for the MH closure 14 years earlier. ILM peeling was not performed during the previous surgeries. The best-corrected visual acuity (BCVA) with the Landolt ring chart was 0.08 at her visit. The minimum MH diameter was 1,240 μm. Inverted ILM flap technique with 20% SF6 gas tamponade was performed for the MH closure. For the inverted ILM flap technique, 25-gauge PPV and ILM staining with indocyanine green were used. The ILM was peeled off for 2 disc diameters around the MH, but the ILM was not removed completely. The ILM was then inverted and covered the MH. Results: One month after surgery, the MH was closed, accompanied by glial cell proliferation spreading from the inverted ILM flap (as reported before). On the other hand, the area of the submacular RPE atrophy, which was already observed 1 week after surgery, gradually increased in size. BCVA improved to 0.3 six months after the surgery. Conclusions: The inverted ILM flap technique may be promising even for persisting large MH which were not closed in previous surgeries, but long-term observation is needed because the detailed behavior of the inverted ILM and the Müller cells after surgery is not yet known.

BackgroundTo 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.MethodsThis 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.ResultsClosure 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).ConclusionInverted 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.

PurposeTo compare the anatomical and visual outcomes of inverted internal limiting membrane (ILM) flap technique with the conventional ILM peeling for idiopathic large macular holes (MHs).MethodsA meta-analysis of randomized control trials (RCTs) using online databases including NCBI PubMed, ClinicalTrials.gov, and ISI Web of Science was performed. Anatomic success and type 1 closure rates, the mean postoperative best-corrected visual acuity (BCVA) and the mean change of BCVA from baseline were analyzed.ResultsOut of 251 articles, four described clinical trials matching the inclusion criteria and were selected. They included 276 eyes (135 eyes in the inverted ILM flap group and 141 eyes in the ILM peeling group). All the studies used gas tamponade, with two studies having a follow-up duration of 3 months, while one study had a follow-up of 6 months and one study– 12 months. The meta-analysis demonstrated that anatomic success and type 1 closure rates (presence of neurosensory retina in MH) were better in the inverted ILM flap technique (odds ratio (OR) = 4.89; 95% confidence interval (CI), 2.09–11.47; P = 0.0003 and OR = 5.23; 95% CI, 2.83–9.66; P<0.00001). Similarly, the inverted flap technique was superior in terms of postoperative logMAR BCVA and mean change of logMAR BCVA from baseline (weighted mean difference (WMD) = 0.17, 95% CI, 0.11 to 0.24, P<0.00001 and WMD = 0.08, 95% CI, 0.01 to 0.16, P = 0.03)ConclusionInverted ILM flap treatment resulted in better closure rates and visual acuity when compared to the standard ILM peeling for large MHs.

Background To evaluate the technique of inverted internal limiting membrane (ILM) flaps for the management of large macular holes and autologous ILM free flaps for non-closing macular holes. Patients and methods All macular holes were treated with pars plana vitrectomy and dual blue assisted ILM flap technique. The inverted ILM flap was created as a primary procedure for large macular holes (diameter > 400 µm). On the other hand, the free ILM flap technique was used as a secondary procedure for non-closing macular holes after failed initial standard procedure. SD-OCT images were taken to assess the anatomical outcome of surgery, while best corrected visual acuity (BCVA) was used to evaluate the functional outcome during a 2-month follow-up. Results All patients underwent successful planned manipulation of the ILM flap. In seven patients/eyes, an inverted ILM flap was created, in three patients/eyes a free ILM flap translocation was performed. All patients achieved complete anatomical closure. Partial microstructural reconstruction, demonstrated on SD-OCT as restoration of the external limiting membrane and the ellipsoid zone, was observed in some cases as early as one month after surgery. Functionally, in comparison to baseline, most of the patients showed improvements in BCVA of 1 to 2 lines at the first postoperative follow-up visit. Conclusions Inverted ILM flaps for large macular holes and free flaps for non-closing macular holes appear to be a safe and effective approach, with favourable short-term anatomical and functional results.

Background The aim of this meta-analysis was to compare morphological and functional outcomes between vitrectomy with the inverted internal limiting membrane (ILM) flap technique and vitrectomy with internal limiting membrane peeling in highly myopic eyes with macular hole- (MH-) induced retinal detachment (MHRD). Methods The PubMed, Web of Science, Embase, and Cochrane Library databases were comprehensively searched from inception to November 10, 2019, for published studies comparing the two techniques for the treatment of MHRD. The outcomes in the collected articles included the postoperative MH closure rate, retinal reattachment rate, and best-corrected visual acuity (BCVA). Review Manager (version 5.3) was used for analyses. Results In total, seven retrospective studies comparing the inverted ILM flap technique with ILM peeling for the treatment of MHRD were included. The MH closure rate was significantly higher in the inverted ILM flap group than in the ILM peeling group at 6 and 12 months after initial surgery (OR = 15.39; 95% CI: 6.68 to 35.43;P < 0.00001 and OR = 12.58, 95% CI: 3.51 to 45.08; P=0.0001), while the retinal reattachment rate was similar in both groups at 6 months after initial surgery (OR = 2.40; 95% CI: 0.89 to 6.50; P=0.08). Besides, the postoperative BCVA was significantly better in the inverted ILM flap group than in the ILM peeling group at 12 months after initial surgery (MD = −0.35; 95% CI: −0.52 to −0.18; P < 0.0001). Conclusions Thus, the MH closure rate and postoperative BCVA may be better with the inverted ILM flap technique than with ILM peeling for myopic MHRD, while the postoperative retinal reattachment rate appears to be similar with both techniques. Therefore, in the future, vitrectomy with the inverted ILM flap technique should be preferred over standard ILM peeling technique for the treatment of MHRD in highly myopic eyes.

Pars plana vitrectomy (PPV) procedures are used for the surgical treatment of macular hole retinal detachment (MHRD) associated with high myopia. Re-detachment of the retina has been reported in MHRD associated with high myopia. Our aim was to evaluate the 1-year outcomes of vitrectomy, performed using an inverted internal limiting membrane (ILM) flap technique with gas tamponade, in five cases of MHRD associated with high myopia. We performed a retrospective review of medical records of five consecutive cases of highly myopic MHRD. The following postoperative data were collected: refractive error, best-corrected visual acuity, intraocular pressure, ophthalmic fundus examination findings, ocular coherence tomography at 1, 3, 6, and 12months postoperatively; duration of the follow-up period; and intra- and postoperative complications. The primary endpoint of the study was the rate of postoperative retinal reattachment and macular hole (MH) closure. Paired t-tests were conducted to evaluate postoperative changes. Mean visual acuity improved significantly (P = 0.008), with an improvement of ≥2 lines on LogMAR value gained in three of the five eyes. Retinal reattachment was maintained in all cases, with no cases of MH reopening identified over the mean follow-up period of 20.2months. No complications were identified in any eye. The inverted ILM flap technique and gas tamponade provided primary retinal reattachment and MH closure over the ≥12-month follow-up period.

BackgroundThe purpose of this study was to compare the anatomical and visual outcomes of inverted internal limiting membrane (ILM) flap technique and internal limiting membrane peeling in large macular holes (MH).MethodsRelated studies were reviewed by searching electronic databases of Pubmed, Embase, Cochrane Library. We searched for articles that compared inverted ILM flap technique with ILM peeling for large MH (> 400 μm). Double-arm meta-analysis was performed for the primary end point that was the rate of MH closure, and the secondary end point was postoperative visual acuity (VA). Heterogeneity, publication bias, sensitivity analysis and subgroup analysis were conducted to guarantee the statistical power.ResultsThis review included eight studies involving 593 eyes, 4 randomized control trials and 4 retrospective studies. After sensitivity analysis for eliminating the heterogeneity of primary outcome, the pooled data showed the rate of MH closure with inverted ILM flap technique group was statistically significantly higher than ILM peeling group (odds ratio (OR) = 3.95, 95% confidence interval (CI) = 1.89 to 8.27; P = 0.0003). At the follow-up duration of 3 months, postoperative VA was significantly better in the group of inverted ILM flap than ILM peeling (mean difference (MD) = − 0.16, 95% CI = − 0.23 to 0.09; P < 0.00001). However, there was no difference in visual outcomes between the two groups of different surgical treatments at relatively long-term follow-up over 6 months (MD = 0.01, 95% CI = − 0.12 to 0.15; P = 0.86).ConclusionVitrectomy with inverted ILM flap technique had a better anatomical outcome than ILM peeling. Flap technique also had a signifcant visual gain in the short term, but the limitations in visual recovery at a longer follow-up was found.