Inverted Internal Limiting Membrane 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.

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.

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.

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.

Biofeedback Training after Successful Inverted Internal Limiting Membrane (ILM)-Flap Technique for High Myopic Macular Hole.

Microperimetric biofeedback training improved visual acuity and fixation stability in patients who previously underwent macular surgery. We aimed to compare the functional results of biofeedback training with the standard of care in patients who underwent successful inverted Internal Limiting Membrane (ILM)-flap technique for high myopic macular holes (hMMH). This was a retrospective, comparative, cohort study. Patients with hMMH after surgical hole closure underwent microperimetric biofeedback using structured light stimulus plus acoustic tone (n = 12; Biofeedback) or standard of care with scheduled visits (n = 11; Control). Best-corrected visual acuity, retinal sensitivity at central 12° (RS) and 4° (CRS) with a mean deviation at central 12° (MD), and fixation stability as bivariate contour ellipse area (BCEA 68%, 95%, and 99%) were assessed at baseline and month 1, 3, 6, and 12. The Mann-Whitney test was used to test the difference between the groups. Baseline functional parameters were not significantly different among the groups. BCVA significantly improved in each group (Biofeedback, p = 0.002; Control, p ≤ 0.02) at all follow-up visits. CRS significantly improved at 6 (p = 0.03) and 12 (p = 0.01) months in the Biofeedback group and at month 12 (p = 0.01) in the Control group. RS (p = 0.001) and MD (p = 0.005) improved at the last follow-up only in the trained group. After training, BCEA 68% and 95% significantly improved (6 and 12 months, p < 0.05). The Biofeedback group had better results in RS (p ≤ 0.02), CRS (p ≤ 0.02), and BCEA 68%, 95%, and 99% (p ≤ 0.01) compared to the Control at all follow-ups. BCVA and MD were better in the Biofeedback group at month 3 (p = 0.01), and month 3 (p = 0.01) and 12 (p = 0.003), respectively. Microperimetric biofeedback can increase retinal sensitivity and stabilize fixation better than the standard care over months after a successful inverted ILM-flap for hMMH.

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.

Perfluoro-n-octane-assisted Superior Inverted ILM Flap without Using the Peeling-off Technique for Large Macular Holes

Purpose: To evaluate the surgical outcomes of a perfluoro-n-octane (PFO)-assisted superior inverted internal limiting membrane (ILM) flap without the peeling-off technique for the treatment of a large macular hole (MH).Methods: This retrospective interventional case series examined 13 eyes with a MH ≥ 400 μm. All eyes underwent 25-gauge pars plana vitrectomy. An ILM flap stained with 0.025% brilliant blue G was made in the superior area of the hole. The ILM in the temporal, nasal, and inferior areas around the hole was not peeled off. The hole was gently covered using the inverted ILM flap, which was stabilized using a small amount of PFO. Fluidair exchange was performed slowly. The small amount of residual PFO was removed by evaporation. The patients were instructed to maintain a facedown position for 1 day postoperatively. Anatomical closure of the hole and visual acuity were assessed postoperatively.Results: The average hole size was 605.08 ± 102.41 μm. Nine eyes had an idiopathic MH, two exhibited age-related macular degeneration, and one each had high myopia and a traumatic MH. All eyes achieved type I closure. The foveal contour improved gradually during follow-up: 92.3% of eyes had a U-shaped fovea, and 61.5% exhibited complete recovery of the ellipsoid zone. The visual acuity improved from 0.91 to 0.55 logarithm of the minimum angle of resolution (&lt;i&gt;p&lt;/i&gt; = 0.003).Conclusions: The PFO-assisted superior inverted ILM flap without peeling-off was effective for stabilizing the flap over the hole and consequently achieving good anatomical and visual outcomes in large MHs.

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.

Flap-Related Complications Following Temporal Inverted Internal Limiting Membrane Flap for Macular Hole Repair.

Here we report three cases of flap-related complications following temporal inverted internal limiting membrane (ILM) flap technique for the repair of macular holes (MH). The first case showed a flap closure pattern in which the MH completely closed at 2 months spontaneously. The second case showed early anatomical and functional improvement provided by an immediate closure of the MH but developed flap contracture and nasally located epiretinal membrane (ERM) at postoperative 18 months. There was no functional deterioration, thus no further intervention was required. In the third case, early postoperative flap dislocation was observed and an additional surgery to reposition the flap was needed. The flap closure pattern observed with inverted ILM flap techniques may represent the ongoing healing process of large MHs and may be related to delayed spontaneous anatomical closure. ILM flap contracture and ERM formation may be a harmless long-term complication. Dislocation of the ILM flap is an unexpected early postoperative complication that may necessitate a second surgery for flap repositioning.

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.

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.

Macular hole reopening after inverted internal limiting membrane flap

Introduction: Here, we present a case of macular hole (MH) reopening after an initial successful closure with an inverted internal limiting membrane (ILM) flap procedure. Case Report: The patient was a 72-year-old Hispanic male who presented with decreased vision in the right eye who was found to have a 431 μm, full-thickness macular hole. The patient underwent three separate 25-gauge pars plana vitrectomies to correct the macular hole. The first involved an inverted ILM flap technique, the second one removal of the flap and the third one subretinal injection of balanced salt solution (BSS). Conclusion: The failure of the inverted ILM flap, we believe, was primarily due to the inferiorly attached flap being pulled down by surface tension of the rising fluid level.

MACULAR BUCKLING COMBINED WITH VITRECTOMY AND INVERTED INTERNAL LIMITING MEMBRANE FLAP TECHNIQUE FOR MACULAR HOLES WITH MACULAR RETINOSCHISIS WITHOUT RETINAL DETACHMENT IN HIGH MYOPIA.

To investigate the outcomes of macular buckling combined with vitrectomy and inverted internal limiting membrane flap technique for highly myopic full-thickness macular hole (FTMH) with macular retinoschisis. Twenty-six eyes of 26 consecutive patients were retrospectively included. Twelve eyes underwent macular buckling alone (buckling group). Fourteen eyes underwent macular buckling and vitrectomy with an inverted internal limiting membrane flap technique (combination group). Patients were followed for at least 9 months. Rates of FTMH closure and macular retinoschisis resolution, best-corrected visual acuity gained at the final visit were evaluated. The mean follow-up time was 13.00 ± 3.16 months. FTMH closed in six eyes (50%) of the buckling group and 13 eyes (92.86%) of the combination group ( P = 0.026) at the final visit. The macular retinoschisis resolution rate was close between two groups (100% vs. 92.86%; P = 1.000). Both groups achieved significant improvement in best-corrected visual acuity (10.42 ± 17.25 and 16.36 ± 10.39 Early Treatment Diabetic Retinopathy Study letters; P = 0.014 and P < 0.001). The combination group achieved slightly more best-corrected visual acuity improvement, but the difference fell short of significance ( P =0.312). Combination of macular buckling and vitrectomy with the inverted internal limiting membrane flap technique could achieve a high FTMH closure rate and significant best-corrected visual acuity improvement in FTMH with macular retinoschisis.

Modified inverted internal limiting membrane flap technique for macular hole closure.

To investigate the efficacy of modified internal limiting membrane (ILM) flap technique combined with vitreous surgery for treating macular holes and examine the outcomes in visual function and anatomic macular hole closure. Retrospective, observational. Between July 1, 2015, and October 1, 2019, the modified inverted ILM flap technique combined with vitreous surgery was used to treat idiopathic macular holes, postoperative progression was then followed for at least 6 months in 96 participants (98 eyes). We modified the method by removing the lower half of the ILM while peeling and inverting the upper half. The mean age of the participants was 65.9 ± 11.9 years (41 men (42.7%) and 55 women (57.3%)). Retrospective evaluations of macular hole diameter, corrected visual acuity, and macular hole closure rates were performed using data from medical records. The mean macular hole diameter was 623.6 ± 207.4μm. The mean corrected visual acuity (logMAR) was 0.79 ± 0.27 before surgery and 0.46 ± 0.35 at 1, 0.35 ± 0.39 at 3, and 0.31 ± 0.36 at 6 months Post surgery, showing significant differences before and after surgery (p = 2.30 × 10- 2). The macular hole closure rate was 98%. The modified inverted ILM flap technique combined with vitreous surgery was an effective method for treating macular holes, resulting in improvement in closure and visual acuity.

Comparative Study of Conventional Inverted ILM Flap Covering and ILM Flap Filling Technique in Idiopathic Macular Hole Treatment: A Meta-Analysis and Systematic Review.

Objective This meta-analysis was performed to evaluate the anatomical efficacy and functional improvement of the conventional inverted internal limiting membrane (ILM), flap covering technique, and ILM flap filling technique for patients with idiopathic macular hole (MH). Methods Literature from Pubmed, Embase, Cochrane Central Register of Controlled Trials, and Web of Science were comprehensively retrieved. The primary outcomes included the MH closure rate and postoperative best-corrected visual acuity (BCVA). The secondary outcomes were the proportion of external limiting membrane (ELM) and ellipsoid zone (EZ) defect recovery. Pooled odds ratios (ORs), weighted mean differences (WMDs), and 95% confidence intervals (CIs) were calculated using STATA 17.0 software. Results 7 studies that contained 139 eyes in the inverted ILM flap covering group and 121 eyes in the ILM flap filling group were selected. Pooled data suggested that the surgical treatment resulted in an overall MH closure rate of up to 97.12% (135/139 eyes) in the inverted ILM flap covering group and 99.17% (120/121 eyes) in the filling group, with no significant difference between the 2 groups (OR = 1.98, 95% CI: 0.55 to 7.09, and P=0.29). Similarly, the 2 techniques demonstrated equal effectiveness on the anatomical closure in MH with the average diameter smaller than 650 μm (OR = 2.17, 95% CI: 0.48 to 9.77, and P=0.31) and larger than 650 μm (OR = 1.58, 95% CI: 0.14 to 17.37, and P=0.71). However, compared with the filling technique, the inverted ILM flap covering technique was superior in postoperative BCVA (WMD = 0.11, 95% CI: 0.04 to 0.18, and P=0.0017) and presented a significantly higher proportion of reconstitution of ELM (OR = 0.02, 95% CI: 0.00 to 0.08, and P < 0.0001) and EZ (OR = 0.11, 95% CI: 0.04 to 0.32, and P=0.0001). Conclusion The inverted ILM flap covering technique was associated with the superior reconstitution of outer layers of the retina, including ELM and EZ, and more improvement in postoperative BCVA than the ILM flap filling technique.

Dissociated Optic Nerve Fiber Layer Appearance after Macular Hole Surgery: A Randomized Controlled Trial Comparing the Temporal Inverted Internal Limiting Membrane Flap Technique with Conventional Peeling

To evaluate the effect of the temporal inverted internal limiting membrane (ILM) flap technique compared with that of conventional ILM peeling on the extent of the dissociated optic nerve fiber layer (DONFL) and retinal sensitivity in patients undergoing macular hole (MH) surgery. Single-center, prospective, open-label, randomized controlled clinical trial. Patients requiring vitrectomy for MHs sized > 250 μm. Patients were randomly assigned (1:1) to 1 of the following 2 groups: (1) the control group undergoing standard ILM peeling and (2) the experimental group (flap group) undergoing the temporal inverted ILM flap technique. The primary outcome measure was the total DONFL score at 3 months after surgery. Important secondary outcomes were microperimetry results, primary MH closure rate, external limiting membrane (ELM) and ellipsoid zone (EZ) recovery rates, and best-corrected visual acuity (BCVA). Sixty-five patients were recruited between February 2018 and July 2020; primary outcome data were available for 60 patients. The median DONFL score was 7.0 (3.0-12.5) in the control group and 5.0 (1.5-8.5) in the flap group at 3 months after surgery (P= 0.145). The focal depressions characteristic of the DONFL were limited to the temporal side of the fovea in the flap group, whereas they were found all around the fovea in the control group on spectral-domain OCT images. The MH closure rate (P= 1), EZ and ELM recovery rates (P= 0.252), and BCVA (P= 0.450) were similar between the 2 groups. The 3-month overall median retinal sensitivity (MRS) (P= 0.142) and MRS improvement (P= 0.916) in the control group were comparable with those observed in the flap group. In addition, there was no significant difference between the 2 techniques when considering the temporal area (P= 0.105) or the nasal area (P= 0.468). The temporal inverted ILM flap technique reduced the extent of the DONFL by preserving the nasal part of the fovea. However, the overall DONFL score was similar between the 2 techniques. In addition, the MRS and BCVA did not differ from those obtained after complete ILM peeling.

Vertical Internal Limiting Membrane Stalk after Macular Hole Surgery

A 62-year-old White woman with a 441-μm wide full-thickness macular hole had a vitrectomy with a temporal inverted internal limiting membrane (ILM) flap in her left eye. After the 6-month follow-up visit, her vision improved to 20/80 with substantially reduced metamorphopsia. She presented with a newly emerged, immobile