Inverted Internal Limiting Membrane Flap 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.

Visual Improvement Despite Macular Pucker After Inverted Internal Limiting Membrane Flap Technique for Idiopathic Macular Hole

Purpose: To report a case of a macular pucker forming after macular hole (MH) repair with the inverted internal limiting membrane (ILM) flap technique, with resolution after secondary inverted ILM flap peeling. Methods: A single case was evaluated. Results: A 76-year-old woman presented with reduced central vision (28 letters) in the right eye. Optical coherence tomography (OCT) identified an idiopathic full-thickness MH measuring 629 µm in diameter. The patient had pars plana vitrectomy with inverted ILM flap formation. One month postoperatively, the visual acuity (VA) in the right eye was 47 letters and OCT confirmed MH closure. However, the patient developed deterioration in the central vision 10 months postoperatively. A macular pucker in the inverted ILM flap region was found on OCT. Repeat vitrectomy with inverted ILM flap peeling was performed. Postoperatively, the VA in the right eye improved to 60 letters and OCT showed resolution of the macular pucker. Conclusions: A complication of the inverted ILM flap technique for MH is formation of a macular pucker in the region of the inverted ILM flap. Secondary inverted ILM flap peeling results in resolution of the macular pucker.

Double flaps of internal limiting membrane for chronic optic pit maculopathy with large outer lamellar hole

A 24-year-old woman presented with very chronic optic pit maculopathy and outer lamellar hole. During vitrectomy, two internal limiting membrane (ILM) flaps were designed and inverted from the temporal to the nasal side to cover the thin-roofed fovea and the optic pit. Two weeks post vitrectomy, the outer lamellar hole de-roofed into a full-thickness macular hole but remained covered with the inverted ILM flap. The hole edges grew centripetally and re-bridged over the next month. By 9 months, the macular hole had closed, schisis settled, and BCVA improved substantially.

Inverted Internal Limiting Membrane Flap Coverage with Autologous Blood Technique after Air-fluid Exchange and Silicone Oil Tamponade for Extensive Macular Hole Retinal Detachment in Highly Myopic Eyes.

To report a technique consisting of inverted internal limiting membrane (ILM) flap coverage with autologous blood after air-fluid exchange and silicone oil tamponade in treating extensive retinal detachment (RD) secondary to a myopic macular hole (MH). Retrospective case series. The technique was applied in 18 eyes with MH-RD extending beyond the equator with a minimum follow-up of 6 months. The procedures for pars plan vitrectomy (PPV) included the following:1) the ILM was peeled to the superior and inferior arcade margins, and except for the ILM in the temporal region, was hinged toward the edge of the MH. 2) Air-fluid exchange was then performed to drain the subretinal fluid (SRF) through the MH with a flute needle, ensuring that a small amount of SRF remained to facilitate ILM flap inversion. 3) The ILM flap was used to cover the MH with the assistance of autologous blood. Six months after surgery, the MH was successfully anatomically closed, and retinal reattachment was observed in all 18 eyes of 18 patients. The mean best-corrected visual acuity (BCVA, logMAR) improved from 2.03 ± 0.61 (ranging from hand motion [HM] [2.6] to finger counting [FC] [2.3]) to 1.23 ± 0.63 (ranging from HM [2.6] to 20/28 [0.15]) (P < 0.01) at 6 months. This surgical technique using an inverted ILM flap combined with autologous blood provides an option for the treatment of extensive MHRD.

Outcomes of inverted internal limiting membrane flap surgery for chronic large macular holes in a sub-Saharan African setting

TopicOutcomes of inverted internal limiting membrane (ILM) flap surgery for chronic large macular holes (MH) in a sub-Saharan Africa setting. PurposeTo report the anatomic and visual outcomes of ILM flap surgery without face-down positioning for eyes with chronic large MH at Eye Foundation Hospital, Lagos, Nigeria. DesignRetrospective, observational study. MethodsCase files of patients who underwent inverted ILM flap surgery for large MH in the retina unit of the Eye Foundation Hospital, Lagos, Nigeria, between January 2022 and December 2022 were reviewed. ResultsThe study included 30 eyes of 29 patients. MH size was between 471 μm and 1530 μm. The mean overall preoperative best corrected logMAR visual acuity was 1.27 ± 0.58. A one-line worsening of preoperative logMAR vision was associated with an increase in MH size by 129.5 μm (p = 0.056). MH closure was achieved in 90% of eyes. There was an improvement in mean best corrected postoperative logMAR visual acuity at 6 months to 0.83 ± 0.49 (p < 0.001). Good visual outcomes were seen in 60.7% of eyes. The remodeling of the external limiting membrane seen in 46.7% of eyes was associated with good visual outcomes (p = 0.04). ConclusionThere was a 90% anatomic closure rate for chronic large MHs that underwent inverted internal limiting membrane flap surgery among our series of patients in a sub-Saharan African setting. Good visual outcomes were seen in 60.7% of eyes, with an overall improvement in logMAR visual acuity.

Enhancing inverted internal limiting membrane flap stability in macular hole retinal detachment by the "viscoelastic agent pool" technique.

To evaluate the surgical anatomical and functional results of "viscoelastic agent pool" technique-assisted stability of inverted internal limiting membrane (ILM) flap in macular hole retinal detachment (MHRD). The innovative surgical technique was carried out on 10 patients with MHRD. The primary outcomes included best corrected visual acuity (BCVA) after surgery, rate of closure of MH, retinal reattachment, and occurrence of complications. The mean age of the individuals was 67.70±8.75 (range, 55-84) years; mean axial length, 29.34±1.53 (range, 27.10-30.93) mm; mean corrected MH diameter, 685.30± 345.65 (range, 172-1325) μm; and average follow-up period, 6.01±1.71 (range, 3.10-8.4) months. In six eyes (60%), the postoperative BCVA showed improvement. All patients had MH closure, and the retinal reattachment rate was 100%. No postoperative complications were noted. The "Viscoelastic agent pool" technique, an innovative surgical approach designed to enhance the stability of the ILM flap, serves as an effective adjunctive procedure for the inverted ILM flap technique. It presents a viable option for patients with MHRD.

Characteristics of fundus autofluorescence imaging at 795 nm and its correlations with postoperative outcomes for idiopathic macular hole.

Vitrectomy combined with internal limiting membrane (ILM) peeling or ILM inverted flap greatly improves hole closure and vision prognosis for idiopathic macular holes (IMH). The application of indocyanine green (ICG) in MH surgery increases the visibility of ILM and the safety of surgery. However, the area of ILM peeling and the state of the flap and a closed hole has not been well observed. Fundus autofluorescence at 7935nm can show the range of ILM peeling and the state of the hole site and ILM flap by monitoring residual ICG postoperatively. However, the characteristics of fundus autofluorescence especially the site of the closed hole, and its relationship with vision prognosis have not been explored. The aim of this project was to find the autofluorescence features of the closed hole and their relation with vision. To investigate the characteristics of fundus autofluorescence imaging after ICG-assisted vitrectomy for IMH and to evaluate the correlations of fluorescence patterns at the MH site with visual acuity and macular anatomic outcomes. We retrospectively evaluated 33 IMH patients (33 eyes) who underwent a 25G pars plana vitrectomy (follow-up, 6-14.5 months). ICG staining (2.5 mg/mL) was either used to remove the internal limiting membrane (ILM) or the inverted ILM flap was overlaid on the hole. After surgery, fluorescence imaging of the fundus was obtained using a scanning laser ophthalmoscope at 795 nm. On fluorescence imaging, the area of ILM peeling in all eyes showed hypofluorescence with no changes over time. The inverted ILM flap (performed in 18 eyes) was positioned on the inferior retina and exhibited early mild hyperfluorescence with blurred edges. This was gradually enhanced up to 3-6 months postoperatively and was then attenuated. MHs showed two distinct patterns on optical coherence tomography: granular (21 eyes) and patchy hyperfluorescence (12 eyes). Best-corrected visual acuity improved postoperatively in all cases (p<0.001, Z=-4.744). VA was worse in the patchy (vs. granular) hyperfluorescence cases (p=0.011, Z=-2.548). The status of the ILM peeling area, ILM flap, and closed MH can be clearly observed using autofluorescence imaging at 795 nm. Fluorescence may be due to ICG staining of the ILM and accumulation in retinal pigment epithelium cells during ICG-assisted surgery. Granular hyperfluorescence at the MH site may indicate good anatomic and visual prognoses.

VERTICAL AND HORIZONTAL METAMORPHOPSIA ONE YEAR AFTER SURGERY FOR MACULAR HOLES ≤ 500 µ m WITH AND WITHOUT INVERTED INTERNAL LIMITING MEMBRANE FLAP.

To investigate the effect of an inverted internal limiting membrane flap (IF) and other factors on metamorphopsia after macular hole surgery. Prospective case series of patients undergoing pars plana vitrectomy with gas tamponade, with either conventional internal limiting membrane peeling (CP) or an IF, for primary idiopathic macular holes ≤ 500 µ m. Vertical and horizontal metamorphopsia were measured as M-scores (degrees) using M-charts preoperatively and at 2, 6, and 12 months postoperatively. Fifty-three eyes of 53 patients were included of whom 27 underwent CP and 26 were treated with an IF. After macular hole surgery, all patients were pseudophakic. Vertical and horizontal metamorphopsia improved from 1.08 (±0.51) and 0.98 (±0.70) preoperatively to 0.58 (±0.37) and 0.45 (±0.36) at 2 months ( P < 0.01), with no further significant improvement at 6 months (0.39 [±0.31], P = 0.07 and 0.31 [±0.28], P = 0.18) or at 12 months (0.37 [±0.30], P = 0.72 and 0.28 [±0.28], P = 0.99). There was no significant difference in the mean vertical and horizontal metamorphopsia between patients with CP and with an IF at 2 months ( P = 0.063, P = 0.10), 6 months ( P = 0.25, P = 0.16), or 12 months ( P = 0.62, P = 0.22). Preoperative vertical M-score improved at 12 months after macular hole surgery by 61% and 64% in the CP and IF groups, respectively ( P = 0.84), and the horizontal M-score by 65% and 71%, respectively ( P = 0.98). The use of an IF has no evident bearing on the degree of postoperative metamorphopsia 12 months after surgical repair of macular holes ≤ 500 µ m.

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.

Surgical outcomes of petalloid multilayered inverted internal limiting membrane flaps in extra-large macular holes.

To analyze the surgical outcomes of petalloid multilayered inverted internal limiting flap using perfluorocarbon liquid (PFCL) in extra-large macular holes (MHs) (minimum linear diameter >550 µm and basal diameter [BD] >1000 µm). This was a prospective interventional series of 103 eyes of 99 patients with extra-large MHs which were treated with 25-gauge pars plana vitrectomy, petalloid multilayered inverted internal limiting membrane flaps under PFCL and 15% perfluoropropane (C3F8) gas tamponade. Intraoperative optical coherence tomography (i-OCT) was used to confirm correct positioning of flaps. Follow-up was at 1 week, 1 month, and 3 months postoperatively. Mean age of patients was 58.282 ± 16.3 years. Mean preoperative best corrected visual acuity (BCVA) was logarithm of minimum angle of resolution (logMAR) 1.206 ± 0.384, and the value at the third month was logMAR 0.793 ± 0.337. Mean minimum linear diameter (MLD) was 711.96 ± 270.744 µm. MLD ranged from 557µm (minimum MLD) to 2657 µm (maximum MLD). Mean BD was 1301.165 ± 425.914 µm. Type 1 closure was seen in 92.2% eyes, 5.8% eyes had type 2 closure, and 1.9% eyes had type 3 closure. Eyes with both type 1 closure (P = 0.001) and type 2 closure (P = 0.009) showed a significant improvement in BCVA postoperatively at 3 months. Petalloid multilayered inverted internal limiting membrane flap under PFCL technique with adjunctive use of i-OCT showed improved morphological and functional outcomes in the treatment of extra-large MHs. We present here a large series of extra-large MHs, in which a novel technique of petalloid multilayered inverted ILM flaps was used.

Surgical Management of Full-Thickness Macular Holes Spontaneously Arising From Lamellar Macular Holes.

Introduction: To review the literature regarding surgical management of full-thickness macular holes (FTMHs) spontaneously arising from lamellar MHs (LMHs). Methods: The literature on surgically managed FTMHs arising from LMHs was reviewed via Ovid MEDLINE and Embase through June 5, 2022. Results: Seventy-six eyes from 16 articles were included. Forty eyes had internal limiting membrane (ILM) peeling, 32 inverted ILM flap techniques, and 4 an unclear surgical technique. The FTMH closure rate was not significantly different between ILM peeling (34/40 [85%]) and the inverted ILM flap techniques (28/32 [88%]) (P = .761). The mean (±SD) logMAR visual acuity improved from 0.64 ± 0.46 to 0.25 ± 0.22 (Snellen 20/87 to 20/36) with ILM peeling (n = 30); similar data were not available for inverted ILM flap techniques. Conclusions: Foveal tissue loss, flat hole edges, and limited retinal hydration may result in inverted ILM flap techniques having outcomes similar to those of ILM peeling in repairing FTMHs from LMHs. Future studies are needed to compare techniques.

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 THREE INTERNAL LIMITING MEMBRANE PEELING TECHNIQUES FOR MYOPIC TRACTION MACULOPATHY WITH HIGH RISK OF POSTOPERATIVE MACULAR HOLE DEVELOPMENT.

To compare three different internal limiting membrane (ILM) peeling techniques, including standard ILM peeling, fovea-sparing ILM peeling, and inverted ILM flap (ILMF), in the treatment of myopic traction maculopathy with high risk of postoperative macular hole development. This retrospective cohort study enrolled 101 eyes suffering from lamellar macular hole combined with myopic traction maculopathy in 98 consecutive patients who underwent vitrectomy with either standard ILM peeling, fovea-sparing ILM peeling, or ILMF from July 2017 to August 2020. All patients were followed up for at least 12 months after surgery. Best-corrected visual acuity, macular anatomical outcomes, and postoperative full-thickness macular hole (FTMH) formation were evaluated. No significant differences were found among the three surgical groups in baseline characteristics. 12 months after surgery, the mean best-corrected visual acuity was significantly improved ( P < 0.001) and showed no significant differences among groups ( P = 0.452). None of the eyes in the ILMF group, five eyes (15.6%) in the standard ILM peeling group, and six eyes (17.1%) in the fovea-sparing ILM peeling group developed a postoperative FTMH ( P = 0.026). Logistic regression showed that the ILM peeling technique was an independent influencing factor for FTMH formation (OR = 0.209, P = 0.014). Compared with the standard ILM peeling or fovea-sparing ILM peeling technique, the ILMF technique resulted in similar visual outcomes but a relatively low incidence of postoperative FTMH in the treatment of lamellar macular hole combined with myopic traction maculopathy. Inverted ILM flap is an effective technique for treating myopic traction maculopathy with high risk of postoperative FTMH development.

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.

ILM Insertion for the Treatment of Macular Hole Associated with Phakic Intraocular Lens Implantation

Purpose: To report a case of macular hole closure using an internal limiting membrane (ILM) flap following implantation of a posterior chamber phakic implantable contact lens (ICL).Case summary: An 18-year-old female patient presented with visual loss of the left eye after ICL implantation. She had high myopia of -12.5 diopter (spherical equivalent) and a corrected visual acuity of 2/100. The fundus photograph and optical coherence tomography showed a full-thickness macular hole measuring 688 µm in width and 976 µm in length. The ILM around the hole was detached from the retinal surface, which was greater in size than the macular hole. The initial surgical intervention involved vitrectomy, inverted ILM flap placement, and gas tamponade. The decrease in gas volume was associated with a loss of the ILM flap. For hole closure, the remaining ILM flap in the peripheral macula was harvested and inserted in the hole during the second surgery. The silicone oil was used for tamponade. One month after ILM insertion, complete closure of the hole was observed. The visual acuity improved to 20/40 after silicone oil removal.Conclusions: A large full-thickness macular hole developed after ICL implantation in a patient with high myopia. Macular hole surgery using ILM insertion and prolonged tamponade closed the hole and effectively improved the visual acuity.

Modified ILM flap technique for macular hole.

Currently, vitrectomy is considered as the first line of treatment in the management of macular holes. Various surgical modalities have been described to obtain anatomical closure. However, there are still challenges when the hole is large and chronic (>400 microns) in nature. Here we describe a modified technique of internal limiting membrane (ILM) peeling which results in the successful closure of such macular holes. To demonstrate modified ILM flap techniques in management of chronic macular holes. Here we have described the role of modified ILM peeling techniques in three different cases such as chronic traumatic macular hole >400 microns, chronic idiopathic macular hole >400 microns and <400 microns. This modified ILM flap technique provides the benefit of an inverted ILM flap, which helps in glial proliferation and also relives tangential traction thereby aiding in successful macular hole closure in chronic cases. https://youtu.be/RKVLd1mSw08.

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.

Inverted Pedicled Internal Limiting Membrane Flap Attached to an Optic Disc with Autologous Blood Clot for Large Macular Holes.

An inverted ILM flap might be accidentally separated from the retina or sucked away during surgery for large macular holes (MHs). This article is to determine the efficacy of a new inverted pedicled internal limiting membrane (ILM) flap attached to an optic disc with an autologous blood clot (ABC) technique for the treatment of large MHs. An inverted pedicled ILM flap connected to the optic disc with ABC was used to treat 12 consecutive patients with significant macular holes (>600 m). The ILM was first peeled off around MH as a semidiameter of about 1.5 diameters of the optic disc. The superior residual ILM was used to produce a pedicled ILM flap that was connected to the optic disc and was later inverted to cover the MH. The macular hole was covered with a repositioned flap larger than 2 MH diameters in an inverted way. ABC was used to fasten the flap, followed by fluid-air exchange with air or C3F8 as tamponade. Spectral domain-optical coherence tomography (SD-OCT) and best-corrected visual acuity (BCVA) were performed at each postoperative follow-up. The mean aperture and base macular hole diameters were 737.9 ± 109.6 µm (range, 607-982 µm) and 1244.3 ± 227.4 µm (range, 975-1658 µm). All macular holes (100%) were closed after a single surgery without intraoperative or postoperative complications related to the ILM transposition technique. At the last postoperative visit, we found one eye with a U-shaped closure, three eyes with W-shaped closures, and eight eyes with V-shaped closures. No postoperative flap closures were noted in all cases. The preoperative mean BCVA was 1.5 ± 0.3 (range, 1.1-2.0). After a mean follow-up of 5.3 ± 4.8 (range, 3-16) months, the postoperative mean BCVA was 0.8 ± 0.2 (range, 0.6-1.1), and the difference was statistically significant (p < 0.05). This novel technique is safe and suitable for large MHs and can be an alternative option for accidental ILM flap loss during other inverted ILM flap operations.

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.