Outer retina reconstruction following inverted internal limiting membrane flap technique for large macular holes.

PURPOSE: The aim of this study is to investigate the outer retina reconstruction using postoperative spectral domain optical coherence tomography (SD OCT) in large diameter macular holes (MHs) treated with the inverted internal limiting membrane (ILM) flap technique. METHODS: A retrospective study of 14 consecutive eyes that had vitrectomy and inverted ILM flap technique for MHs with a base diameter of 400 µ or greater. Preoperative and postoperative SD OCT images were assessed for MH closure and for outer retina presence; represented by the external limiting membrane (ELM) and ellipsoid zone (EZ), in the subfoveal and parafoveal areas. RESULTS: The average MH base diameter was 963 µ. Postoperative SD-OCT revealed an absence of the outer retina in six eyes, a continuous (regular) presence of the outer retina in four eyes, and a discontinuous (interrupted) presence in four eyes. There was an inverse relationship between MH size and presence or absence of ELM and EZ. A larger MH base diameter size was associated with a higher probability of an absent ELM and EZ (P = 0.04). Eyes in which an outer retina was present postoperatively achieved 6/18 and better vision compared to eyes without (P = 0.08). CONCLUSION: The outer retina in some large MHs treated with ILM flap technique can undergo reconstitution and remodeling which improves over time. The average size for MHs with complete reconstitution was 652 µ, 855 µ for those with interrupted reconstitution, and 1242 µ for eyes with no outer retina reconstruction. This suggests that MHs having a size within the limit of the no outer retina reconstitution MH group may be candidates for other surgical techniques in which postoperative outer retina presence is expected.

Inverted Internal Limiting Membrane Technique Maintains Macular Hole Closure in Retinal Detachment Following Macular Hole Repair.

Recent advances in macular hole surgery have significantly improved the rates of anatomical success. One important advance is the dye-assisted peeling of the internal limiting membrane (ILM) around the hole. In large holes (<400 µ), sometimes, ILM peeling alone is not enough to achieve closure, and this may be improved by inverting part of the peeled membrane and using it to cover the macular hole or inverting and tucking the ILM flap into the hole. In this case report, a patient with large full-thickness macular hole underwent a hole repair with an inverted ILM flap technique. The eye developed a subsequent retinal detachment with large collection of subretinal fluid beneath the repaired hole, but the hole remained intact, suggesting that the adhesive forces binding an inverted flap to the edges of a repaired macular hole appear to be strong enough to maintain structural integrity of the closed hole even in the presence of a macula-involving retinal detachment with large subretinal fluid collection.