Inverted Inverted Internal Limiting Membrane Flap Technique Research Articles

Comparative Evaluation of Standard ILM Peel With Inverted ILM Flap Technique In Large Macular Holes: A Prospective, Randomized Study.

To compare the outcomes of inverted internal limiting membrane (ILM) flap technique (IFT) with the standard ILM peel (SIP) for large macular holes (MHs). This is a prospective, randomized study in which 100 patients with idiopathic MHs with minimum linear dimension of 600 μm or greater were recruited. Group 1 underwent SIP and group 2 underwent IFT. Best-corrected visual acuity (BCVA), type of MH closure, and multifocal electroretinogram (mfERG) were evaluated at presentation, 1 week, 1 month, and 3 months postoperatively. Mean postoperative BCVA was 0.86 ± 0.19 in group 1 and 0.67 ± 0.3 in group 2 at 3 months postoperatively (P = .001). Type 1 closure was observed in 34.04% of patients in group 1 and in 62.79% of patients in group 2 (P = .02). mfERG showed improvement in both groups. IFT provides superior outcomes compared to SIP and, hence, could be considered as the surgical modality of choice in large MH. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:236-240.].

Inverted internal limiting membrane flap technique for large macular holes: a systematic review and single-arm meta-analysis.

The aim of this systematic review was to determine the anatomical outcome-macular hole (MH) closure rate-and functional outcome-visual acuity (VA) improvement rate-of the inverted internal limiting membrane (ILM) flap technique for large MH. We searched for articles on large MH (> 400μm) treated with inverted ILM flap technique in databases as of December 1, 2017. And single-arm meta-analysis was performed for the primary outcome of MH closure rate and the secondary outcome of VA improvement rate. In addition, we searched and pooled studies treating large MH with indocyanine green (ICG)-assisted ILM peeling as the reference. R software (version 2.15.2) was used for analysis. This review includes eight studies that used inverted ILM flap technique to treat large MH (> 400μm). Based on the single-arm meta-analysis performed in R 2.15.2, the pooled MH closure rate and VA improvement rate following inverted ILM flap technique were 95% (95% CI, 88 to 98%) and 75% (95% CI, 62 to 85%), respectively, in fixed-effect models. There was no substantial methodological heterogeneity. In addition, we selected four studies on large MH treated with ICG-assisted ILM peeling as the reference. The fixed-model pooled MH closure rate and VA improvement rate were 87% (95% CI, 79 to 92%) and 57% (95% CI, 46 to 68%), respectively. Inverted ILM flap technique should be an effective and safe method for treating large MH, with high closure rates and good VA improvement. However, further studies in large randomized controlled trials on minimizing surgical complications and understanding the mechanism of this technique are necessary.

Inverted Internal Limiting Membrane Flap Technique for Extra Large Macular Holes

Aim: To investigate the outcome of the inverted Internal Limiting Membrane (ILM) flap technique for extra large idiopathic macular holes (MHs).Methods: A retrospective non-comparative surgical case series of seven eyes of 7 patients with MHs (base diameter of at least 1000 ?m) was conducted. All the MHs were treated using pars plana vitrectomy and brilliant blue G (BBG)-assisted inverted ILM flap technique. Spectral Domain- Optical Coherence Tomography (SD-OCT) images were used to assess the anatomical outcomes of surgery including the macular microstructure, while Best Corrected Snellen Visual Acuity (BCSVA) was used to evaluate the functional outcomes.Results: The average MH size was 1241microns and average symptom duration was nineteen months. All eyes achieved successful anatomical closure and there was no occurrence of a flat open type closure. SD-OCT microstructural study revealed a reconstruction of the Ellispod Zone (EZ) and External Limiting Membrane (ELM), in only 3 eyes. There was an improvement in visual acuity in 5 eyes, while 2 eyes maintained the same as pre operative vision. The largest increase in post operative visual acuity gain was a 4-line improvement in Best Corrected Snellen Visual Acuity (BCSVA) noted in one of the 3 eyes with reconstructed EZ and ELM. The 3 months symptom duration in this patient was the shortest in this series.Conclusion: Inverted ILM flap technique is a safe and effective approach for the management of extra large chronic idiopathic MHs with demonstrably good anatomical and limited functional results in a majority of cases. Postoperative reconstruction of the microstructure is however seen only in a minority of eyes. Despite an absence of the outer retina (EZ and ELM), some eyes still experience an improvement in vision. The symptom duration may play a vital role in functional outcome in this subset of extra large chronic MHs.

Intraoperative OCT for inverted ILM flap technique

PurposeTo evaluate the use of intraoperative spectral‐domain optical coherence tomography (iSD‐OCT) for large macular hole (MH) surgery using inverted internal limiting membrane (ILM) flap technique.MethodsWe analyzed 7 consecutive cases of iSD‐OCT assisted pars plana vitrectomy (PPV) with inverted ILM flap technique for large and chronic MHs. iSD‐OCT was performed using Rescan 700 (Zeiss, Oberkochen, Germany). iSD‐OCT data were post‐processed and analyzed postoperatively (study of tissue behavior).ResultsIn all cases iSD‐OCT imaging allowed the surgeon to carry on the procedure without significant time consumption. The iSD‐OCT imaging assisted: 1) to find the safe place on the retina while starting ILM peeling; 2) to control the formation of the inverted ILM flap; 3) to conduct the inversion of the ILM flap over MH. iSD‐OCT allowed to keep safe positioning of the vitreoretinal instruments.ConclusionsiSD‐OCT is a strong supporting tool during PPV, that gives prompt information about tissue behavior and surgical maneuvers. Inverted ILM flap technique for large MH can be performed in more controlled and save way without interruption of the surgical workflow.

Observation of single-layered inverted internal limiting membrane flap technique for macular hole with retinal detachment in high myopia

Objective: To compare the outcome of pars plana vitrectomy (PPV) with a single-layered inverted internal limiting membrane (ILM) flap versus PPV with ILM peeling for the treatment of macular hole associated retinal detachment (MHRD) in high myopia. Methods: In a retrospective cohort study, PPV with 2 kinds of adjuvant surgical procedures were used in 35 moderately high myopia eyes with MHRD. These eyes were divided into 2 groups: group 1 (17 eyes) receiving PPV and ILM peeling and group 2 (18 eyes) receiving PPV with a single-layered inverted ILM flap. Anatomical reattachment of the retina, macular hole closure, and best-corrected visual acuity (BCVA) were measured at 6 months after surgery. Results: The retina was successfully reattached in all cases. The difference of the retinal reattachment rate between the two groups was not statistically significant (Fisher's exact test, P=1.000). The rate of macular hole closure was 47.1% in group 1 (8 eyes) and 88.9% in group 2 (16 eyes). The difference of the macular hole closure rate between the two groups was statistically significant (Fisher's exact test, P= 0.012). Significant improvement in logarithm of minimal angle of resolution (logMAR) BCVA was achieved in both groups. There was no difference in the initial, final, or improved logMAR BCVA in the 2 groups. Conclusion: Single-layered inverted ILM flap technique effectively helps close the macular hole in moderately high myopia with MHRD. This may prevent the possible redetachment from the macular hole. (Chin J Ophthalmol, 2017, 53: 338-343).

The Effect of an Inverted Internal Limiting Membrane Flap on Retinal Function after Macular Hole Surgery

To study the effect of an inverted internal limiting membrane (ILM) flap on the retina. Prospective case series. Twenty-nine patients with large (>400 μm) unilateral macular holes underwent surgery using a modified inverted ILM flap technique. The macular ILM was peeled, and a large (2-3 disc diameter) ILM flap was made on the superior side of the hole, and then the flap was inverted on the inferior side. In all patients, multifocal electroretinograms (mfERGs) were recorded from operated eyes and normal fellow eyes. The peak time and amplitude of N1, P1, and N2 in the focal ERG from the upper retina without the ILM flap and those from the lower retina with the ILM flap were evaluated. In 14 patients, microperimetry was also performed in both eyes, and the averaged sensitivity was measured from the upper and lower areas. The peak times of P1 and N2 from the upper and lower retina were significantly longer in operated eyes than in the fellow eyes (P1 upper and lower: P < 0.04, N2 upper: P < 0.01, and N2 lower: P < 0.04), although we could not identify a significant difference in peak time and amplitude of N1, P1, and N2 between the upper retina and lower retina in both eyes (fellow eye-N1 amplitude: P > 0.2, N1 peak time: P > 0.5, P1 amplitude: P>0.9, P1 peak time: P > 0.4, N2 amplitude: P > 0.9, N2 peak time: P > 0.9; operated eye-N1 amplitude: P>0.8, N1 peak time: P > 0.4, P1 amplitude: P > 0.6, P1 peak time: P > 0.4, N2 amplitude: P > 0.9, N2 peak time: P > 0.9). We could not observe a significant difference in sensitivity between the upper and lower retinas in both eyes (fellow eye: P= 0.28, operated eye: P= 0.66). The results of this study revealed no significant difference between the upper retina without the ILM flap and the lower retina with the ILM flap, suggesting that an inverted ILM flap has little effect on retinal function.

EFFICACY OF THE INVERTED INTERNAL LIMITING MEMBRANE FLAP TECHNIQUE WITH VITRECTOMY FOR RETINAL DETACHMENT ASSOCIATED WITH MYOPIC MACULAR HOLES.

To evaluate the anatomical and functional outcome of the inverted internal limiting membrane (ILM) flap technique with vitrectomy for retinal detachment associated with macular hole (MHRD) in highly myopic eyes. In this retrospective observational study, 21 eyes with MHRD that underwent vitrectomy with conventional ILM peeling (ILM-peeling group, n = 11) or the inverted ILM flap technique (ILM flap group, n = 10) combined with C3F8 tamponade were enrolled in this study. The initial retinal reattachment rate, macular hole closure rate, and postoperative visual acuity at the final visit were compared between the ILM-peeling group and ILM flap group. There was no significant difference in the retinal reattachment rate between ILM-peeling and ILM flap groups (91% and 100%, respectively). The macular hole closure rate in the ILM flap group was 80% (8 of 10 eyes), and was significantly higher than 36% (4 of 11 eyes) in the ILM-peeling group (P = 0.039). Among 12 eyes that achieved macular hole closure, there was no significant difference in median visual acuity after vitrectomy between the ILM flap group and ILM-peeling group (logMAR unit [Snellen acuity]: 1.0 [20/200] and 0.76 [20/125], respectively, P = 0.300). Compared with conventional ILM peeling, the inverted ILM flap technique was more effective for macular hole closure after vitrectomy for MHRD in myopic eye but showed no advantage in the postoperative visual outcome in this study.

Long-term surgical outcomes of the inverted internal limiting membrane flap technique in highly myopic macular hole retinal detachment.

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

Inverted internal limiting membrane flap technique as a useful procedure for macular hole-associated retinal detachment in highly myopic eyes

PurposeTo determine whether the inverted internal limiting membrane (ILM) flap technique contributes to high reattachment and closure rates in patients with macular hole-associated retinal detachment (MHRD).Patients and methodsIn all, 15 eyes of 15 patients with MHRD undergoing 25-gauge pars plana vitrectomy with the inverted ILM flap technique or ILM peeling. The patients were divided into the inverted ILM flap technique group (6 eyes) and ILM peeling group (9 eyes). The logarithm of minimal angle of resolution best-corrected visual acuity (BCVA) and retinal attachment and macular hole closure rates were compared between the two groups before and after surgery.ResultsNo significant differences were found in the pre- and postoperative BCVA at 1 and 3 months after surgery in either group (inverted ILM flap technique group, preoperatively 1.04±0.55, 1 month 0.95±0.30, 3 months 0.83±0.22; ILM peeling group, preoperatively 1.00±0.44, 1 month 1.05±0.38, 3 months 1.06±0.49; P>0.05, respectively). The postoperative BCVA at 6 months after surgery was significantly better in the inverted ILM flap technique group than in the ILM peeling group (inverted ILM flap technique group, 0.62±0.35; ILM peeling group, 1.02±0.41, P=0.045). The improvement in BCVA was significantly better in the inverted ILM flap technique group than in the ILM peeling group (inverted ILM flap technique group, –0.41±0.29; ILM peeling group, 0.02±0.36; P=0.021). The primary macular hole closure rates were 100% in the inverted ILM flap technique group and 55.5% in the ILM peeling group. The primary reattachment rates were 100% in the inverted ILM flap technique group and 55.5% in the ILM peeling group. The primary macular hole closure and reattachment rates were not significantly different in both groups (P=0.056, respectively).ConclusionThe inverted ILM flap technique is a useful procedure for MHRD in highly myopic eyes.

Clinical and histological evaluation of large macular hole surgery using the inverted internal limiting membrane flap technique.

PurposeThe aims of this study were to analyze optical coherence tomography (OCT) imaging of large macular holes (MHs) treated with inverted internal limiting membrane (ILM) flap technique and to perform a histological examination of an ILM-like membrane tissue obtained during vitrectomy.Patients and methodsThis is a retrospective observational case study. Nine patients, comprising of five males and four females, showing large and myopic MHs, underwent pars plana vitrectomy (PPV) with inverted ILM flap technique assisted by brilliant blue G (BBG) staining. Ophthalmological findings including visual acuity and OCT were investigated based on medical records. Formalin-fixed paraffin-embedded tissue section of an ILM-like membrane was submitted for immunohistochemistry with glial fibrillary acidic protein (GFAP).ResultsILM was clearly stained with BBG in eight patients, whereas the ILM in one case revealed no staining with BBG during PPV. Visual acuities improved to >0.2 LogMAR in six patients. The complete closure of MH following PPV with inverted ILM technique was eventually achieved in all patients determined by OCT imaging (100%). Only one patient showed recovery of ellipsoid zone and interdigitation zone following the surgery. Elongation of outer nuclear layer was noted in three eyes. The ILM-like membrane not stained with BBG histologically revealed an amorphous structure admixed with GFAP-positive mononuclear cell infiltration.ConclusionPPV with inverted ILM flap technique achieved 100% closure rates with favorable configuration at an initial surgery in large MHs. Our histopathological data also suggest that even BBG staining-negative membrane may be a useful material for autologous transplantation to the hole.

Inverted Internal Limiting Membrane Flap Technique for Repair of Large Macular Holes: A Short-term Follow-up of Anatomical and Functional Outcomes.

Background:Inverted internal limiting membrane (ILM) flap technique has recently been reported in a limited number of studies as an effective surgical technique for the management of large macular holes (MHs) with fair MH closure rates as well as gains in visual acuity. In the current study, longitudinal changes in multi-focal electroretinogram (mfERG) responses, best-corrected visual acuity (BCVA) and spectral-domain optical coherence tomography (SD-OCT) were evaluated in eyes with large MHs managed by this technique.Methods:A prospective noncontrolled interventional study of eight patients (eight eyes) with large MHs (minimum diameter >400 μm) was conducted. All MHs were treated with pars plana vitrectomy and indocyanine green-assisted inverted ILM flap technique. SD-OCT images were used to assess the anatomical outcomes of surgery while BCVA and mfERG were used to evaluate the functional outcomes during a 3-month follow-up.Results:All patients underwent successful intended manipulation and translocation of the ILM flap without flap dislocation and achieved complete anatomical closure. Partial microstructural reconstruction, demonstrated on SD-OCT as restoration of the external limiting membrane and the ellipsoid zone, was observed in all cases as early as 1 month after surgery. Functionally, as compared to baseline, all patients showed improvements in BCVA and all but one in mfERG response during follow-up. However, Pearson's test revealed no significant correlations between BCVA and mfERG responses of the fovea and of the macular area at each evaluation time point.Conclusions:Inverted ILM flap technique appeares to be a safe and effective approach for the management of large idiopathic MHs with favorable short-term anatomical and functional results. Postoperative reconstruction of the microstructure generally shows good consistency with improvements in both BCVA and mfERG response, of which the latter might be a supplement for the former in postoperative functional follow-up.

Viscoat Assisted Inverted Internal Limiting Membrane Flap Technique for Large Macular Holes Associated with High Myopia.

Purpose. To investigate the surgical outcomes of Viscoat® assisted inverted internal limiting membrane (ILM) flap technique for large macular holes (MHs) associated with high myopia. Design. Prospective, interventional case series. Methods. Fifteen eyes of 15 patients with high myopia underwent vitrectomy and Viscoat assisted inverted ILM flap technique to treat MH without RD. Patients were followed up over 6 months. The main outcome measures were MH closure evaluated by optical coherence tomography (OCT) and best-corrected visual acuities (BCVAs). Result. MH closure was observed in all eyes (100%) following the initial surgery. Type 1 closure was observed in 13 eyes (86.7%); type 2 closure was observed in the remaining 2 eyes (13.3%). Compared to the preoperative baseline, the mean BCVA (logarithm of the minimum angle of resolution) improved significantly at 3 months and 6 months after surgery (P = 0.025, 0.019, resp.). The final BCVA improved in 10 eyes (66.7%), remained unchanged in 3 eyes (20.0%), and worsened in 2 eyes (13.3%). Conclusion. Vitrectomy combined with Viscoat assisted inverted ILM flap technique is an effective treatment for large MHs in highly myopic eyes. It may increase the success rate of the initial surgery and enhance the anatomical and functional outcomes.

TEMPORAL INVERTED INTERNAL LIMITING MEMBRANE FLAP TECHNIQUE FOR A MACULAR HOLE PATIENT UNABLE TO MAINTAIN POSTOPERATIVE PRONE POSITIONING

To report the surgical technique and efficacy of the temporal inverted internal limiting membrane (ILM) flap technique for a patient with an idiopathic macular hole (MH) who is unable to maintain postoperative prone positioning. Case report. A 73-year-old man with a Stage III MH in his left eye was scheduled to undergo surgery. Owing to his inability to maintain postoperative prone positioning for continuous placement of a transdermal bladder catheter after radical cystoprostatectomy to treat urinary bladder cancer, he underwent pars plana vitrectomy combined with the temporal inverted ILM flap technique and intraocular sulfur hexafluoride gas tamponade. The technique included ILM peeling at a temporal area of the macula to create one 2-disk-diameter semicircular ILM flap and inversion of the ILM flap nasally to cover the MH. Optical coherence tomography showed that MH closure started from the top of the MH just beneath the covered ILM flap; the closure process gradually extended toward the bottom of the MH. The well-aligned fovea recovered in 5 weeks postoperatively. The visual acuity was 20/200 preoperatively and improved to 20/50 postoperatively. The temporal inverted ILM flap technique, a simple surgery to treat MHs, provides scaffolding for retinal gliosis and may facilitate bridge formation between the walls of the MH beneath the flap. The procedure may be a good option to achieve MH closure without postoperative prone positioning.

Efficacy of Inverted Internal Limiting Membrane Flap Technique for the Treatment of Macular Hole in High Myopia

To determine the effect of pars plana vitrectomy (PPV) with inverted internal limiting membrane (ILM) flap technique for macular hole with or without retinal detachment in highly myopic eyes. Retrospective, interventional case series. Ten eyes of 10 patients with macular hole with (4 eyes) or without (6 eyes) retinal detachment in high myopia (axial length more than 26.5mm) were treated by PPV with inverted ILM flap technique. Macular hole closure was observed in 8 eyes (80%) following the initial surgery (in 5 eyes without retinal detachment and in 3 eyes with retinal detachment). In 4 eyes with retinal detachment caused by macular hole, retinas of 3 eyes were reattached by the initial surgery. Postoperative best-corrected visual acuity improved by more than 2 lines in 5 eyes (50%), was unchanged in 4 eyes (40%), and worsened by more than 2 lines in 1 eye (10%). Inverted ILM flap technique might contribute to a high closure rate of macular hole and be a preferable adjuvant to the treatment of macular hole in high myopia with or without retinal detachment.

Surgical outcomes of inverted internal limiting membrane flap technique for large macular hole

We are presenting the initial results of inverted internal limiting membrane (ILM) flap technique for large macular hole. Five eyes of five patients with large diameter macular hole (>700 μm) were selected. All patients underwent inverted ILM flap technique for macular hole. Anatomical closure and functional success were achieved in all patients. There was no loss of best-corrected visual acuity in any of the patients. Inverted ILM flap technique in macular hole surgery seems to have a better hole closure rates, especially in large diameter macular holes. Larger case series is required to assess the efficacy and safety of this technique.

Inverted Internal Limiting Membrane Flap Technique for Large Macular Holes

Large macular holes usually have an increased risk of surgical failure. Up to 44% of large macular holes remain open after 1 surgery. Another 19% to 39% of macular holes are flat-open after surgery. Flat-open macular holes are associated with limited visual acuity. This article presents a modification of the standard macular hole surgery to improve functional and anatomic outcomes in patients with large macular holes. A prospective, randomized clinical trial. Patients with macular holes larger than 400 μm were included. In group 1, 51 eyes of 40 patients underwent standard 3-port pars plana vitrectomy with air. In group 2, 50 eyes of 46 patients underwent a modification of the standard technique, called the inverted internal limiting membrane (ILM) flap technique. In the inverted ILM flap technique, instead of completely removing the ILM after trypan blue staining, a remnant attached to the margins of the macular hole was left in place. This ILM remnant was then inverted upside-down to cover the macular hole. Fluid-air exchange was then performed. Spectral optical coherence tomography and clinical examination were performed before surgery and postoperatively at 1 week and 1, 3, 6, and 12 months. Visual acuity and postoperative macular hole closure. Preoperative mean visual acuity was 0.12 in group 1 and 0.078 in group 2. Macular hole closure was observed in 88% of patients in group 1 and in 98% of patients in group 2. A flat-hole roof with bare retinal pigment epithelium (flat-open) was observed in 19% of patients in group 1 and 2% of patients in group 2. Mean (or median) postoperative visual acuity 12 months after surgery was 0.17 (range, 0.1-0.6) in group 1 and 0.28 (range, 0.02-0.8) in group 2 (P = 0.001). The inverted ILM flap technique prevents the postoperative flat-open appearance of a macular hole and improves both the functional and anatomic outcomes of vitrectomy for macular holes with a diameter greater than 400 μm. Spectral optical coherence tomography after vitrectomy with the inverted ILM flap technique suggests improved foveal anatomy compared with the standard surgery.