Abstract
Purpose To assess the safety and effectiveness of the single-layered inverted internal limiting membrane (ILM) flap technique for treating chronic, large, or highly myopic macular holes (MHs). Methods The medical records of 20 eyes of 20 consecutive Japanese patients with large MHs (n=6) (minimal diameter, >400 μm), chronic MHs (n=2) (symptom duration, >24 months), MHs in high myopia (n=11) (axial length, >26 mm), and MHs in a patient unable to maintain prone positioning postoperatively (n=1) were reviewed retrospectively. All patients underwent 25-gauge pars plana vitrectomy and the temporal inverted ILM flap technique. A semicircular ILM notch was made temporally two disc diameters from the MH using a 25-gauge knife, and the ILM was peeled temporally to create a semicircular ILM flap using a 25-gauge forceps. The single-layered ILM flap was inverted in a nasal direction to cover the MH. When an epiretinal membrane (ERM) was present, it was peeled before the ILM flap was inverted. Results The MHs closed successfully in all (100%) eyes postoperatively. In the MHs associated with an ERM, after hole closure, gradual foveal deformation occurred in both the area from which the ILM was not peeled and the ILM flap inverted side. Conclusions The single-layered inverted ILM flap technique, a simple surgery to treat MHs, provides scaffolding for retinal gliosis and may facilitate bridge formation between the walls of the MH under the flap. Considering the 100% success rate of MH closure, this technique seems to be effective and safe for treating chronic, large, or highly myopic MHs and MHs in patients unable to maintain postoperative prone positioning. In the MHs associated with ERMs, gradual foveal deformation was observed after ERM peeling. Further studies are needed to minimize surgical complications and understand the mechanism of this technique. This trial is registered with UMIN000035091.
Highlights
Internal limiting membrane (ILM) peeling has become a standard procedure in the surgical treatment of idiopathic macular holes (MHs) in recent years. e satisfactory results with single-procedure MH closure rates of 50% to 88% for large MHs exceeding 400 μm [1, 2], 40% to 83% for chronic MHs [3, 4], 63% to 90% for MHs with high myopia [5,6,7], and 60% to 100% without postoperative face-down positioning [8, 9] have been reported; surgical closure of these MHs remains challenging
Michalewska et al first reported the inverted ILM flap technique as a new surgical strategy that was performed successfully to treat large MHs and MHs in highly myopic eyes for which a poor singleprocedure MH closure rate was expected [10, 11]. e temporal inverted ILM flap technique, a modified form in which the ILM is peeled from the temporal side of the fovea only was performed to treat large MHs. is procedure recently was reported to decrease the risk of surgical trauma and dissociated optic nerve fiber layer appearance with the same anatomic and functional results compared with the original inverted ILM flap technique [12]
Some complications related to the inverted ILM flap technique have been reported, including worse postoperative visual acuity (VA) than the preoperative level [15, 16], expansion of retinal pigment epithelial (RPE) atrophy [17], and prevention of MH closure and/or functional recovery of the outer retina by the inverted ILM flap [18]. e current study reports the effectiveness of the singlelayered inverted ILM flap technique performed to treat chronic, large, or highly myopic MHs and MHs in patients unable to maintain postoperative prone positioning and foveal deformation that have not been reported previously
Summary
Internal limiting membrane (ILM) peeling has become a standard procedure in the surgical treatment of idiopathic macular holes (MHs) in recent years. e satisfactory results with single-procedure MH closure rates of 50% to 88% for large MHs exceeding 400 μm [1, 2], 40% to 83% for chronic MHs [3, 4], 63% to 90% for MHs with high myopia [5,6,7], and 60% to 100% without postoperative face-down positioning [8, 9] have been reported; surgical closure of these MHs remains challenging. Michalewska et al first reported the inverted ILM flap technique as a new surgical strategy that was performed successfully to treat large MHs and MHs in highly myopic eyes for which a poor singleprocedure MH closure rate was expected [10, 11]. E temporal inverted ILM flap technique, a modified form in which the ILM is peeled from the temporal side of the fovea only was performed to treat large MHs. is procedure recently was reported to decrease the risk of surgical trauma and dissociated optic nerve fiber layer appearance with the same anatomic and functional results compared with the original inverted ILM flap technique [12]. E current study reports the effectiveness of the singlelayered inverted ILM flap technique performed to treat chronic, large, or highly myopic MHs and MHs in patients unable to maintain postoperative prone positioning and foveal deformation that have not been reported previously Some complications related to the inverted ILM flap technique have been reported, including worse postoperative visual acuity (VA) than the preoperative level [15, 16], expansion of retinal pigment epithelial (RPE) atrophy [17], and prevention of MH closure and/or functional recovery of the outer retina by the inverted ILM flap [18]. e current study reports the effectiveness of the singlelayered inverted ILM flap technique performed to treat chronic, large, or highly myopic MHs and MHs in patients unable to maintain postoperative prone positioning and foveal deformation that have not been reported previously
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