ILM Flap Repositioning for Persistent Macular Hole.

We present a case of a persistent macular hole which was initially treated by pars plana vitrectomy with the inverted ILM flap technique. In a second procedure, the internal limiting membrane (ILM) flap was mobilized from its perifoveal adherence to the retina and peeled back to its adherence at the foveal ring. The eye was filled with 25% C2F6 gas. Three weeks after the second procedure, closure of the hole was observed. Best corrected visual acuity increased from 20/400 to 20/50. We assume that contractile elements within the ILM may cause perifoveal adhesion and centrifugal effects preventing macular hole closure. If macular hole closure does not occur after surgery with an inverted ILM flap, it is worth to peel back the existing flap again towards the foveal edge in order to induce hole closure and preserve the benefits of flap surgery. If the flap is only attached to the foveal ring, centripetal contraction could lead to annular closure of the macular hole. If the flap is lost, alternative surgical methods for refractory MHs should be considered.

360° inverted internal limiting membrane flap technique for idiopathic macular holes ≤ 250 µm, > 250 and ≤ 400 µm, and > 400 µm.

PURPOSE: To study the functional and morphological results of the inverted internal limiting membrane (ILM) flap technique for the treatment of idiopathic macular holes (MHs) sized ≤ 250 µm, > 250 and ≤ 400 µm, and > 400 µm. METHODS: Retrospective, nonrandomized interventional study of 65 eyes with primary idiopathic MHs who underwent pars plana vitrectomy (PPV) with the inverted ILM flap technique. Closure rate, best-corrected visual acuity (BCVA), and integrity of external limiting membrane (ELM) and ellipsoid zone (EZ) were analyzed by optical coherence tomography (OCT). RESULTS: Total closure rate was 96.9% with 100% in the ≤ 250 µm group, 100% in the > 250 and ≤ 400 µm group, and 91.7% in the > 400 µm group. Mean BCVA significantly improved after treatment: from 0.7 to 0.3 LogMAR in the ≤ 250 µm group (n = 15, p < 0.001), from 0.9 to 0.4 LogMAR in the > 250 and ≤ 400 µm group (n = 26, p < 0.001), and from 1.0 to 0.5 LogMAR in the > 400 µm group (n = 24, p < 0.001). A total of 16 patients had follow-up over 14 months: BCVA increased from 0.9 LogMAR preoperatively to 0.4 after 1 month (p < 0.00001) and to 0.3 LogMAR after 14 months (p = 0.03). A recovered ELM could be observed in 56.3% after 1 month and in 87.5% after 14 months. A recovered EZ could be observed in 18.8% after 1 month and in 68.8% after 14 months. CONCLUSION: The study demonstrates a high closure rate with corresponding restitution of outer retinal layers. In addition to its importance for the treatment of MHs > 400 µm, the inverted ILM flap technique also appears to be effective and safe for the treatment of MHs < 400 µm. TRIAL REGISTRATION: WHO: DRKS00021241.