Inverted Internal Limiting Membrane Flap Technique Research Articles

Efficacy of inverted inner limiting membrane flap technique for macular holes of ≤400 μm: A systematic review and meta-analysis.

To evaluate the efficacy of inverted internal limiting membrane (ILM) flap technique in full-thickness macular holes (MHs) with a size of ≤400 μm compared to the ILM peeling technique. Related literatures that compared inverted ILM flap and ILM peeling in MHs ≤ 400 μm were reviewed by searching electronic databases including Pubmed, EMbase, ClinicalTrials.gov, and Cochrane Library up to April 2023. The primary outcome measure was hole closure rate, and the secondary outcome measures were the mean postoperative best-corrected visual acuity (BCVA), retinal sensitivity, and outer status of the retinal layers, including the external limiting membrane and ellipsoid zone. The quality of the articles was assessed according to the revised version of the Cochrane risk-of-bias tool for randomized trials or the Newcastle-Ottawa scale. In the case of heterogeneity, a sensitivity analysis was conducted, and publication bias was visually evaluated using a funnel plot. This review included six studies with 610 eyes for the primary outcome and 385 eyes for the secondary outcomes, which were two randomized control trials and four retrospective studies. Pooled data revealed that the overall MH closure rate was 99.4% in the inverted ILM flap group and 96.2% in the ILM peeling group, without significant difference between the two groups (odds ratio = 3.91; 95% confidence interval, 0.82~18.69; P = 0.09). The inverted ILM flap technique did not have a favorable effect on the BCVA, retinal sensitivity, or recovery of the outer retinal layers. These results were consistent with those of the subgroup analysis of the different follow-up periods. No significant publication bias was observed. In eyes with MHs of ≤400 μm, both techniques demonstrated excellent surgical outcomes without significant differences. Therefore, surgical techniques can be selected according to surgeon preferences.

Short-term results of surgical treatment in large idiopathic macular hole cases.

To evaluate results of the surgical treatment for large stage (Stage 3 and 4) idiopathic macular hole cases with and without ILM flap technique. Sixty eyes of 60patients diagnosed with idiopathic macular hole (MH) were included in the study. Complete ophthalmologic examination and SD-OCT examination were performed in all eyes. MH stages, MH base diameter, height and closest distance were measured quantitatively. Postoperative and 3months visits were evaluated. The mean age of the cases was 65.0 ± 8.0 (range 30-84) years, there were 31 (51.7%) female and 29 (48.3%) male patients with a mean follow-up period of 18.1 ± 16.7 (range 3-63)months. The mean best corrected visual acuity recorded at preoperative and third month control visits were 0.89 ± 0.40(preoperative) logMAR, 0.82 ± 0.60(3month) logMAR (p < 0.05). The mean MH index was 0.48 ± 0.16, the closest hole distance was 517.86 ± 210.89µm and mean basal diameter of holes was 947.78 ± 361.90µm and the average height was 448.93 ± 79.80 microns. There was no statistically significant difference between anatomic results of macular hole surgery with (n = 22) and without (n = 38) flap in terms of hole closure (86.4% vs. 92.1% p > 0.05). In 90% (54 cases) of the cases, closure was observed after the first surgery. Two eyes that failed macular hole surgery were reoperated. In one of these eyes, anatomical success was obtained with macular hole massage and mechanical cytumulation. However, anatomical success could not be achieved in the other eye. CONCLUSıON: In the treatment of large macular holes, pars plana vitrectomy, internal limiting membrane peeling with/without flap and gas tamponade demonstrated high anatomical and functional success.

PREDICTIVE FACTORS OF SURGICAL SUCCESS WITH THE INVERTED INTERNAL LIMITING MEMBRANE FLAP TECHNIQUE.

To present new morphologic features correlating with functional and anatomical outcomes of the inverted internal limiting membrane flap technique in full-thickness macular hole. A retrospective study of 51 successful and 22 failed full-thickness macular hole surgeries. In all eyes, preoperative spectral domain optical coherence tomography (SD-OCT) or swept source optical coherence tomography (SS-OCT) were reviewed. The presence of supraretinal pigment epithelium granular deposits, presence of an epiretinal membrane or epiretinal proliferation, visibility of posterior hyaloid, continuity of the interdigitation zone or external limiting membrane, presence of cystoid spaces, irregular surface of the margins of full-thickness macular hole, visibility of the suprachoroidal space, and diameters of full-thickness macular hole were analyzed. In multivariate analysis, the success of the first surgery depended solely on the absence of epiretinal membrane ( P < 0.05).In univariate analysis, the success of the first surgery was correlated moreover with the absence of preoperative supraretinal pigment epithelium granular deposits ( P = 0.0010), the absence of an epiretinal proliferation ( P = 0.0060), and the absence of an irregular border of the hole ( P = 0.010). In multivariate analysis, epiretinal membranes were a negative prognostic factor for macular hole closure when the inverted internal limiting membrane flap technique was used. Worse final visual acuity was observed in patients with primary anatomical failure, even if the hole was successfully closed during the second intervention.

Temporal inverted internal limiting membrane flap technique for myopic macular hole retinal detachment reconstruction.

To examine the effects of the temporal inverted internal limiting membrane (ILM) flap technique for foveal reconstruction in patients with highly myopic macular hole-associated retinal detachment (MHRD). A retrospective case series analysis of four patients (four eyes) with MHRD was conducted. The foveal optical coherence tomography changes following treatment using the temporal inverted ILM flap technique were evaluated. In Patient 1, the ILM bridged the macular hole and residual subretinal fluid on postoperative day 6, and complete retinal reattachment was achieved at 19 months. Patient 2 exhibited reduced retinal detachment, with visible ILM inversion and macular hole closure after 14 days. In Patient 3, macular hole closure and fovea formation had occurred by day 25, and the ILM flap was visible. At 2 months, the outer collagenous layer connection in the central fovea and recovery of the external limiting membrane and ellipsoid zone were observed. Patient 4 had a "white hole" MHRD, with macular hole closure achieved on postoperative day 20, albeit with a suboptimal foveal shape. The temporal inverted ILM flap technique in conjunction with vitrectomy facilitates foveal reconstruction in patients with successful treatment of MHRD, and this reconstruction process can be observed by optical coherence tomography.

Anatomical and functional results after vitrectomy with conventional ILM peeling versus inverted ILM flap technique in large full-thickness macular holes

BackgroundAim of the study was to compare success rate and functional outcome following pars plana vitrectomy (PPV) with conventional internal limiting membrane (ILM) peeling versus ILM flap technique for full-thickness idiopathic macular holes (FTMH).MethodsRetrospective analysis of consecutive eyes with FTMH having undergone vitrectomy with sulfur hexafluoride (SF6) endotamponade 25% at the University Medical Center Rostock, Germany (2009–2020). Eyes were divided according to applied surgical technique (ILM peeling [group P] versus ILM flap [group F]). Inclusion criteria were macular hole base diameters (MH-BD) ≥ 400 μm plus axial length ≤ 26.0 mm. Each group was divided into two subgroups based on macular hole minimum linear diameter (MH-MLD): ≤ 400 μm and > 400 μm. Exclusion criteria were FTMH with MH-BD < 400 μm, trauma, myopia with axial length > 26.0 mm or macular schisis. Demographic, functional, and anatomical data were obtained pre- and postoperatively. Preoperative MH-BD and MH-MLD were measured using optical coherence tomography (OCT; Spectralis®, Heidelberg Engineering GmbH, Heidelberg, Germany). Main outcome parameter were: primary closure rate, best-corrected visual acuity (BCVA), and re-surgery rate.ResultsOverall 117 eyes of 117 patients with FTMH could be included, thereof 52 eyes underwent conventional ILM peeling (group P) and 65 additional ILM flap (group F) technique. Macular hole closure was achieved in 31 eyes (59.6%) in group P and in 59 eyes (90.8%) in group F (p < 0.001). Secondary PPV was required in 21 eyes (40.4%) in group P and in 6 eyes (9.2%) in group F. Postoperative BCVA at first follow-up in eyes with surgical closure showed no significant difference for both groups (MH-MLD ≤ 400 μm: p = 0.740); MH-MLD > 400 μm: p = 0.241).ConclusionAnatomical results and surgical closure rate following ILM flap technique seems to be superior to conventional ILM peeling for treatment of FTMH.

Comparison of anatomical and functional outcomes of different surgical techniques in myopic macular hole without retinal detachment.

To define the anatomic and functional outcomes of pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling, inverted ILM flap and free ILM patch graft technique for the treatment of myopic macular hole (MH) without retinal detachment. Sixty-four eyes of 64 patients who underwent PPV for myopic MH were included. Group 1 consists of patients underwent ILM peeling (n=26), and Groups 2 and 3 consists of patient underwent free ILM patch graft (n=20) and inverted ILM flap procedure (n=18) respectively. Outcomes following surgery were MH closure and best corrected visual acuity (BCVA) in logMAR at 6mo. Closure of MH was obtained in 20 eyes (76.9%) of the Group 1, in 16 eyes (80%) of the Group 2 and in 16 eyes (88.9%) of the Group 3. The mean preoperative and postoperative BCVA was 1.60±0.53 logMAR and 1.27±0.58 logMAR, respectively (P<0.05). There was no significant difference in the postoperative BCVA and anatomical closure rates in the three groups. Although the anatomical closure rate did not differ significantly in the groups, closure of MH tended to be better in the inverted ILM flap technique group at 6mo. Different surgical techniques may provide favorable visual and anatomical results for myopic MH surgery. ILM flap techniques offer higher closure rates compared to ILM peeling technique. However, in terms of visual outcomes, the study reveals no difference in three surgical techniques.

Pars plana vitrectomy with internal limiting membrane flap versus pars plana vitrectomy with conventional internal limiting membrane peeling for large macular hole.

Macular hole (MH) is a full-thickness defect in the central portion of the retina that causes loss of central vision. According to the usual definition, a large MH has a diameter greater than 400 µm at the narrowest point. For closure of MH, there is evidence that pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling achieves better anatomical outcomes than standard PPV. PPV with ILM peeling is currently the standard of care for MH management; however, the failure rate of this technique is higher for large MHs than for smaller MHs. Some studies have shown that the inverted ILM flap technique is superior to conventional ILM peeling for the management of large MHs. To evaluate the clinical effectiveness and safety of pars plana vitrectomy with the inverted internal limiting membrane flap technique versus pars plana vitrectomy with conventional internal limiting membrane peeling for treating large macular holes, including idiopathic, traumatic, and myopic macular holes. The Cochrane Eyes and Vision Information Specialist searched CENTRAL, MEDLINE, Embase, two other databases, and two trials registries on 12 December 2022. We included randomized controlled trials (RCTs) that evaluated PPV with ILM peeling versus PPV with inverted ILM flap for treatment of large MHs (with a basal diameter greater than 400 µm at the narrowest point measured by optical coherence tomography) of any type (idiopathic, traumatic, or myopic). We used standard methodological procedures expected by Cochrane and assessed the certainty of the body of evidence using GRADE. We included four RCTs (285 eyes of 275 participants; range per study 24 to 91 eyes). Most participants were women (63%), and of older age (range of means 59.4 to 66 years). Three RCTs were single-center trials, and the same surgeon performed all surgeries in two RCTs (the third single-center RCT did not report the number of surgeons). One RCT was a multicenter trial (three sites), and four surgeons performed all surgeries. Two RCTs took place in India, one in Poland, and one in Mexico. Maximum follow-up ranged from three months (2 RCTs) to 12 months (1 RCT). No RCTs reported conflicts of interest or disclosed financial support. All four RCTs enrolled people with large idiopathic MHs and compared conventional PPV with ILM peeling versus PPV with inverted ILM flap techniques. Variations in technique across the four RCTs were minimal. There was some heterogeneity in interventions: in two RCTs, all participants underwent combined cataract-PPV surgery, whereas in one RCT, some participants underwent cataract surgery after PPV (the fourth RCT did not mention cataract surgery). The critical outcomes for this review were mean best-corrected visual acuity (BCVA) and MH closure rates. All four RCTs provided data for meta-analyses of both critical outcomes. We assessed the risk of bias for both outcomes using the Cochrane risk of bias tool (RoB 2); there were some concerns for risk of bias associated with lack of masking of outcome assessors and selective reporting of outcomes in all RCTs. All RCTs reported postoperative BCVA values; only one RCT reported the change in BCVA from baseline. Based on evidence from the four RCTs, it is unclear if the inverted ILM flap technique compared with ILM peeling reduces (improves) postoperative BCVA measured on a logarithm of the minimum angle of resolution (logMAR) chart at one month (mean difference [MD] -0.08 logMAR, 95% confidence interval [CI] -0.20 to 0.05; P = 0.23, I2 = 65%; 4 studies, 254 eyes; very low-certainty evidence), but it may improve BCVA at three months or more (MD -0.17 logMAR, 95% CI -0.23 to -0.10; P < 0.001, I2 = 0%; 4 studies, 276 eyes; low-certainty evidence). PPV with an inverted ILM flap compared to PPV with ILM peeling probably increases the proportion of eyes achieving MH closure (risk ratio [RR] 1.10, 95% CI 1.02 to 1.18; P = 0.01, I2 = 0%; 4 studies, 276 eyes; moderate-certainty evidence) and type 1 MH closure (RR 1.31, 95% CI 1.03 to 1.66; P = 0.03, I² = 69%; 4 studies, 276 eyes; moderate-certainty evidence). One study reported that none of the 38 participants experienced postoperative retinal detachment. We found low-certainty evidence from four small RCTs that PPV with the inverted ILM flap technique is superior to PPV with ILM peeling with respect to BCVA gains at three or more months after surgery. We also found moderate-certainty evidence that the inverted ILM flap technique achieves more overall and type 1 MH closures. There is a need for high-quality multicenter RCTs to ascertain whether the inverted ILM flap technique is superior to ILM peeling with regard to anatomical and functional outcomes. Investigators should use the standard logMAR charts when measuring BCVA to facilitate comparison across trials.

Characteristics and outcomes of full-thickness macular holes created during vitrectomy for proliferative diabetic retinopathy.

To investigate the clinical features, management, and prognosis of full-thickness macular holes (FTMHs) inadvertently created during vitrectomy for eyes with proliferative diabetic retinopathy (PDR) and fibrovascular proliferation (FVP). Eyes with PDR and FVP that had intraoperatively created FTMHs were retrospectively collected as the study group, and age- and sex-matched subjects with PDR and FVP who did not have intraoperative FTMHs were selected as the control group. Fundus abnormalities, optical coherence tomography (OCT) features, and anatomical and functional outcomes were compared between the two groups. Eleven eyes of 11 patients (5 male and 6 female) were identified as the study group. Follow-up duration was 36.8 ± 47.2months. FTMHs were managed by ILM peeling or the inverted ILM flap technique. Anatomical success and MH closure were achieved in 100% of eyes in the study group. In comparison tothe controlgroup, the study group hada higher proportion of condensed prefoveal tissue (63.6% vs. 22.7%, p = 0.028), anda higher ratio of silicone oil tamponade (63.6% vs. 18.2%, p = 0.014), whereas there were no differences in preoperative and final BCVA, and the severity, activity, and locations of FVP between thetwo groups. Condensed prefoveal tissue was a risk factor of FTMHs created during operation for eyes with PDR and FVP. The ILM peeling or the inverted ILM flap technique may be beneficial for the treatment with favorable anatomical and functional outcomes.

RWC Update: Vitrectomy Surgery in a Pre-Phthisical Eye; Update on the Surgical Management of Macular Holes: The Inverted ILM Flap Technique and How It Revolutionized Macular Hole Surgery; Retinal Arteriovenous Malformation.

RWC Update: Vitrectomy Surgery in a Pre-Phthisical Eye; Update on the Surgical Management of Macular Holes: The Inverted ILM Flap Technique and How It Revolutionized Macular Hole Surgery; Retinal Arteriovenous Malformation.

Short-Term Clinical Results After ILM Removal and Inverted ILM Flap for Macular Hole Repair - A Single-Center Retrospective Experience.

To compare results after ILM peeling and ILM inverted flap technique utilized the repair of full thickness macular holes, irrespective of their size. Pre- and postoperative data of 109 patients who suffered from a full thickness macular hole were retrospectively analyzed. Forty-eight patients were treated with an inverted ILM flap technique, 61 patients were treated with ILM peeling. All patients received a gas tamponade. The primary endpoint was macular hole closure as demonstrated by OCT scanning. Secondary endpoints were best corrected visual acuity and clinical complication rates. For small and medium-sized macular holes the closure rates in the ILM flap technique group were 100% and 94%, respectively. For ILM peeling, the closure rate was identical (95%). For large macular holes, the closure rate was 100% in the flap versus 50% in the ILM peeling group, but visual acuity improved in both groups (ILM flap p=0.001, ILM peeling p=0.002). In both treatment groups, larger holes were associated with a reduced final visual outcome. For medium-sized macular holes, visual acuity significantly improved only in the ILM peeling group. Both techniques were associated with minimal and comparable side effects. In our limited series, the inverted ILM flap technique for repair of macular holes demonstrated a high closure rate. For large MHs, we saw a trend towards a better closure rate in the flap technique compared to ILM peel only. However, final visual acuity showed no significant difference between the groups. Clinical results and complications appeared to be comparable in both groups.

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

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). 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. 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. 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.

Inverted Internal Limiting Membrane Flap versus Internal Limiting Membrane Insertion Technique for Large Macular Holes: A Meta-Analysis

ABSTRACT Purposes This meta-analysis aimed to compare and evaluate the morphological and functional outcomes between the inverted internal limiting membrane (ILM) flap and ILM insertion techniques in the treatment of large macular holes (MHs). Methods The PubMed, Embase, and Cochrane Library databases were searched for relevant studies comparing the two techniques for the treatment of large MHs. The primary outcome measures included the MH closure rate, preoperative and postoperative best-corrected visual acuity (BCVA), MH closure patterns, and external limiting membrane (ELM) and ellipsoid zone (EZ) recovery. Statistical analyses were performed using RevMan 5.3 software. Results Two randomized controlled trials and four retrospective studies were included in this meta-analysis. The MH closure rate did not significantly differ between the two groups (P = .93). Postoperative BCVA was not significantly different between the two groups at 3 months (P = .20) or 6 months (P = .51). ELM and EZ recovery were also similar between the two groups. However, the results for postoperative BCVA and outer retinal structure recovery tended to favor the ILM flap group based on the forest plot. There was no significant difference between the two groups for the U-shape (P = .26), V-shape (P = .65), and W-shape closure types (P = .38). Conclusions Our meta-analysis provides evidence that the MH closure rate and visual function outcomes are similar between the ILM flap and ILM insertion techniques in large MHs. However, based on the forest plot, postoperative BCVA and outer retinal layer reconstruction tended to favor the ILM flap technique. Further studies with larger sample sizes are required to confirm the superiority of the ILM flap to the ILM insertion technique.

The Outcome Of The Inverted Internal Limiting Membrane Flap Technique For The Repair Of Large Idiopathic Macular Holes.

Full-thickness macular hole is defined as an anatomical defect in the fovea that spans from the internal limiting membrane to the retinal pigment epithelium, assessed by spectral domain optical coherence tomography. The Objectives of the study are to determine the anatomical and visual outcome in patients undergoing pars plana vitrectomy along with inverted internal limiting flap closure in large idiopathic full-thickness macular holes (>400 μm). A prospective interventional study was conducted at a tertiary teaching eye hospital in Karachi, where patients of either gender and having macular holes greater than >400 μm were recruited. The study was conducted From January 9 to July 8, 2022, and all patients underwent pre-operative fundus examination and pars plana vitrectomy with inverted ILM flap closure. Data was entered and analyzed using SPSS 23. Follow-ups were conducted at 1 and 3 months. A total of 94 patients were enrolled with a mean age of 49.17±13.8 years. The mean duration of symptoms was 3.1±1.4 months. The mean pre-operative macular hole diameter was 854.31±08.36 μm and Stage 3 and 4 MH was present in 36.2% and 63.8% of patients, respectively. Anatomical closure was achieved in 93.6% of eyes (n=88/94). Pre-operative mean BCVA was LogMAR 0.90±0.24, which improved to LogMAR mean 0.70±0.27 at the final follow-up. As of the last follow-up, 92.6% of patients showed improved visual outcomes, with a mean three-line improvement in Snellen lines. After data stratification, no statistically significant result was obtained. The use of the inverted ILM flap technique resulted in improved anatomical and visual outcomes, in cases of large idiopathic macular holes.

Macular morphology after macular hole surgery using the inverted internal limiting membrane flap technique.

To investigate the influence of an excess inverted internal limiting membrane (ILM) flap that covers the fovea in idiopathic macular hole (i-MH) surgery on postoperative visual acuity and macular morphology. This retrospective study included 66 patients with an i-MH who underwent vitrectomy using the inverted ILM flap technique. They were divided into three groups: normal morphology (N), detached ILM (D), or ILM proliferation (P) in the parafoveal area. They were followed up for at least 6 months, and their best-corrected visual acuity (BCVA), central retinal thickness (CRT), and parafoveal retinal thickness (PRT) were measured. There were no significant differences in pre- or postoperative mean BCVAs or postoperative CRTs among the groups. The postoperative inferior PRTs were 319.2±38.0, 377.1±60.6, and 373.1±67.3 μm in the N, D, and P groups, respectively (P vs. D group, p=0.963; P vs. N group, p=0.008; N vs. D group, p=0.004). Regardless of the postoperative morphology of the inverted ILM flap, there was no effect on postoperative BCVA or CRT.

Repeat Surgery following Temporal Inverted ILM Flap Technique: Next Step after Primary Failure.

We aimed to report our surgical experience with repeat surgery as the next step after an unsuccessful hole closure with the primary single-layered temporal inverted flap technique (IFT). We identified cases with persistent macular holes by reviewing the records of eyes that underwent IFT between October 2018 and October 2021. These cases were evaluated for hole features, anatomical closure, and visual improvement before and after the first and second surgeries. In addition, the technique applied in repeat surgery was recorded. Optical coherence tomography (OCT) images at follow-up were used to evaluate the flap position. A persistent hole was identified in 11 (6.4%) of 172patients who underwent IFT. An inferotemporal displacement was observed in seven eyes, while no flap could be identified in the OCT images of the other four eyes. In the second surgery, the old flap was reinverted in one eye, and a new flap was created from the superior region in five eyes and the nasal region in the other five eyes and was stabilized under perfluorocarbon liquid. A gas tamponade (C3F8/SF6) was used in all patients at the end of surgery. The minimum hole diameter was > 400 µm in all eyes and 100% closure was achieved after the second surgery. Visual acuity gain of ≥ 3 lines was observed in 9 of the 11 eyes (81.8%). The mean visual acuity increase at the last follow-up was significant (p = 0.008). With single-layer temporal IFT in the primary surgery of macular holes, unsuccessful results may be observed due to the flap displacement in the early period. In our series, IFT was applied again with the use of the old flap or the creation of a new flap in the second surgery of the persistent holes, and successful results were obtained.

Management of unresolved optic disc pit maculopathy with human amniotic membrane patch implant: A case report.

Inverted Inner Limiting Membrane (ILM)-flap approach can fail in the treatment of Optic disc pit maculopathy (ODPM). We report a surgical technique involving human amniotic membrane (hAM) patch implant to treat unresolved ODPM after inverted (ILM)-flap technique. One patient with decreased visual acuity (1 LogMar) after unsuccessful inverted ILM-flap technique to treat ODPM, underwent hAM patch implant and was evaluated. A surgical approach including a 2 mm size graft patch of hAM implantation over the optic disc pit followed by fluid-air exchange was performed. A gas endotamponade was finally used. The patient was instructed to maintain face-down position for the first three days after surgery. The hAM patch remained detectable over the pit for the entire 6-months follow-up. The ODPM gradually resolved and visual acuity partially recovered to 0.17 LogMar during follow-up. No postoperative complications or recurrence were reported. hAM patch implant may be effective to manage ODPM after unsuccessful inverted ILM-flap.

AUTOLOGOUS NEUROSENSORY RETINA TRANSPLANTATION FOR TREATING TRAUMATIC MACULAR HOLE

Abstract. Macular hole (MH) is a defect of the neuroretina in the foveal central, which may result in the inadequacy of high acuity vision or in complete vision loss [1]. Traumatic macular hole (TMH) is the second most common cause of MH globally. TMH is defined as the hole in the macular region of the retina caused by the mechanical stress or hitting by an object [2]. Knapp and this team described the very first case of TMH in 1869 [3]. Commonly, the MH can be closed by using internal limiting membrane (ILM) peel with gas or air tamponade [4]; inverted ILM flap technique [5]; or autologous ILM flap6. However, these techniques are not suitable for closing the large MH. The success of Autologous Neurosensory Retina Transplantation (ANRT) by Grewal and Mahmoud (2016) has opened the new ventures for treating complicated MH [7]. In the present case report, we used the technique proposed by Grewal and Mahmoud with some intraoperative variables to treat a traumatic MH [7,8].

Clinical Observation of Anatomical and Visual Outcomes of Macular Hole after Inverted Internal Limiting Membrane Flap in Patients with Idiopathic Macular.

To investigate anatomical and visual outcomes of macular hole (MH) after inverted internal limiting membrane (ILM) flap technique for idiopathic macular hole (IMH). A total of 13 IMH cases diagnosed in Shanxi Eye Hospital between January 2015 and June 2016 were included in the study. All patients underwent vitrectomy combined with indocyanine green-assisted inverted ILM flap technique. The MH closure rate, best-corrected visual acuity (BCVA), changes of ellipsoid zone (EZ), and external limiting membrane (ELM) were examined before operation and one, three, and six months after operation. Furthermore, 488 nm fundus autofluorescence (FAF) and spectral domain optical coherence tomography (SD-OCT) were used to observe the dynamic changes in function of macular area after surgery. One month after the surgery, the MH closure rate was 100% and the visual acuity (VA) was stable, with no recurrence. Additionally, the average logMAR BCVA before operation was 1.208 ± 0.158, and this value became 0.877 ± 0.105 one month after the operation, showing a significant decrease. Three months after surgery, the average logMAR BCVA was 0.792 ± 0.103, which was significantly lower than the level one month after the surgery but much higher than that six months after surgery (0.708 ± 0.131). Besides, the diameter of the EZ defect of the postoperative one month, three months, and six months was (1377.46 ± 198.65) μm, (964.62 ± 336.26) μm, and (817.08 ± 442.99) μm, respectively. In postoperative one month, three months, and six months, the diameter of the ELM defect diameter was (969.62 ± 189.92) μm, (649.92 ± 413.15) μm, and (557.62 ± 412.50) μm, respectively. The diameter of both EZ and ELM defects was significantly reduced with the passage of time after surgery. Inverted ILM flap technique can reconstruct macular anatomical structure and improve VA. This technique is effective for the treatment of IMH with large MH minimum diameter and base diameter.

Surgical classification for large macular hole: based on different surgical techniques results: the CLOSE study group

BackgroundThe CLOSE study group proposes an updated surgical classification for large macular holes based on a systematic review of new treatments. Recently, many new techniques have been introduced to treat large full-thickness macular holes (FTMH); although the indications are not clear. An updated surgical classification is needed to help surgical decision-making.MethodsWe gathered published series by the CLOSE Study Group members and from literature search until June 2021. Techniques included: internal limiting membrane peeling (ILM peeling), ILM flaps, macular hydrodissection (macular hydro), human amniotic membrane graft (hAM), and autologous retinal transplantation (ART). Within each technique, chi-square test assessed association between the minimal linear diameter (MLD) (in µm) and closure rate; the postoperative best-corrected visual acuity (BCVA) gains were compared among groups.ResultsData extraction included 31 published articles: total of 1135 eyes. Eyes were divided into the following groups: ILM peel (n: 683), ILM Flap (n: 233), macular hydrodissection (n: 64), hAM (n: 59), and ART (n: 96). The initial BCVA and size were heterogenous between the groups. ILM peel showed the best results in large FTMH ≤ 535 µm (closure rate 96.8%); adjusted mean BCVA: 0.49 (LogMAR) with a statistical difference among groups. Large FTMH between 535 and 799 µm: ILM flap technique showed better results (closure rate 99.0%); adjusted mean BCVA: 0.67(LogMAR); also with a statistical difference. For large FTMH ≥ 800 µm more invasive techniques are required. Use of hAM, macular hydrodissection and ART showed higher closure rates for this category (100%, 83.3% and 90.5% respectively), and adjusted mean BCVA varied from 0.76 to 0.89. Although there was no statistical difference between those techniques for this group due to the smaller number of cases.ConclusionsThe CLOSE study group demonstrated the potential usefulness of a new surgical classification for large FTMHs and propose OCT biomarkers for use in clinical practice and future research. This new classification demonstrated that Large (400–550 µm) and X-Large (550–800 µm) holes can be treated highly successfully with ILM peel and ILM flap techniques, respectively. Further studies are necessary for the larger FTMHs (XX-Large and Giant), using the CLOSE classification, in order to determine which technique is better suited for each hole size and characteristics.

Comparative study of conventional internal limiting membrane peeling versus temporal inverted internal limiting membrane flap for large macular hole treatment.

To compare the anatomical, morphological, and functional outcomes of the conventional internal limiting membrane (ILM) peeling versus temporal inverted ILM flap technique for large full-thickness macular holes (FTMHs). Sixty eyes of 60 patients with a minimum base diameter >600 μm were included in this retrospective interventional study. Patients were divided into conventional ILM peeling (Group 1) and temporal inverted ILM flap (Group 2) groups. The hole closure rate, best-corrected visual acuity (BCVA), ellipsoid zone (EZ), and external limiting membrane (ELM) defects were analyzed at baseline and 6 months after surgery. Hole closure was achieved in 24/32 (75.0%) cases of Group 1 and 27/28 (96.4%) cases of Group 2 (P = 0.029). The mean BCVA (logMAR) changed from 1.23 ± 0.47 to 0.70 ± 0.29 logMAR in Group 1 and from 1.03 ± 0.36 to 0.49 ± 0.24 logMAR in Group 2 at 6 months (P < 0.001 in both cases). U-shaped closure was observed in 5 (15.6%) eyes in Group 1 and 19 (67.9%) eyes in Group 2 (P < 0.001). The total restoration rates of ELM and EZ were significantly higher in the temporal inverted ILM flap group (P = 0.002, P = 0.001, respectively). The study results suggested that the FTMH closure rate, recovery of the outer retinal layers, and, consequently, the post-operative BCVA were better with the temporal inverted ILM flap technique than with the conventional ILM peeling for larger than 600 μm macular holes.