Successful Management of Familial Exudative Vitreoretinopathy with a Large Macular Hole Using Inverted Internal Limiting Membrane Flap Technique.

Introduction: This case report aims to shed light on a rare presentation of familial exudative vitreoretinopathy (FEVR) co-existing with a large full-thickness macular hole (FTMH) in a 16-year-old male and discuss its successful surgical management, thereby adding to the limited existing knowledge on this topic. Case Presentation: Over an 8-month period, the patient had experienced progressively worsening visual blurring and distortion in his left eye. Following a comprehensive examination, diagnosis confirmed FEVR and an accompanying large FTMH. It was hypothesized that this unusual manifestation resulted from the tractional forces exerted by a thick posterior vitreous membrane and a thin epiretinal membrane - a distinctive attribute of FEVR. The patient underwent surgical intervention, which included pars plana vitrectomy (PPV), internal limiting membrane (ILM) peeling, gas tamponade, and the inverted ILM flap technique. Postoperative outcomes were favorable, with the FTMH successfully closed and substantial improvement observed in the patient's visual acuity at the 3-month follow-up visit. Conclusion: This case report highlights a rare association of FEVR with FTMH, thereby broadening our understanding of potential complications in patients with FEVR. The successful surgical intervention reinforces the utility of the PPV and the inverted ILM flap technique in managing such complications. It underscores the need for clinicians to maintain vigilance for such atypical manifestations in FEVR patients.

Characteristics and outcomes of full-thickness macular holes created during vitrectomy for proliferative diabetic retinopathy.

PURPOSE: To investigate the clinical features, management, and prognosis of full-thickness macular holes (FTMHs) inadvertently created during vitrectomy for eyes with proliferative diabetic retinopathy (PDR) and fibrovascular proliferation (FVP). METHODS: Eyes with PDR and FVP that had intraoperatively created FTMHs were retrospectively collected as the study group, and age- and sex-matched subjects with PDR and FVP who did not have intraoperative FTMHs were selected as the control group. Fundus abnormalities, optical coherence tomography (OCT) features, and anatomical and functional outcomes were compared between the two groups. RESULTS: Eleven eyes of 11 patients (5 male and 6 female) were identified as the study group. Follow-up duration was 36.8 ± 47.2 months. FTMHs were managed by ILM peeling or the inverted ILM flap technique. Anatomical success and MH closure were achieved in 100% of eyes in the study group. In comparison to the control group, the study group had a higher proportion of condensed prefoveal tissue (63.6% vs. 22.7%, p = 0.028), and a higher ratio of silicone oil tamponade (63.6% vs. 18.2%, p = 0.014), whereas there were no differences in preoperative and final BCVA, and the severity, activity, and locations of FVP between the two groups. CONCLUSION: Condensed prefoveal tissue was a risk factor of FTMHs created during operation for eyes with PDR and FVP. The ILM peeling or the inverted ILM flap technique may be beneficial for the treatment with favorable anatomical and functional outcomes.

Inverted Internal Limiting Membrane Flap versus Internal Limiting Membrane Insertion Technique for Large Macular Holes: A Meta-Analysis.

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.

Comparative study of conventional internal limiting membrane peeling versus temporal inverted internal limiting membrane flap for large macular hole treatment.

Purpose: 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). Methods: 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. Results: 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). Conclusion: 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.

Pars plana vitrectomy combined with inverted internal limiting membrane flap technique for treating macular hole retinal detachment in high myopia / 国际眼科杂志(Guoji Yanke Zazhi)

AIM: To investigate the clinical efficacy of pars plana vitrectomy(PPV)combined with inverted internal limiting membrane flap technique in the treatment of macular hole retinal detachment(MHRD)in high myopia.METHODS: A retrospective clinical study was conducted. A total of 63 patients(64 eyes)with high myopia and MHRD who treated at our hospital from October 2017 to October 2021 were selected as research subjects. They were divided into two groups according to different surgery, with 34 cases(35 eyes)who received PPV combined with inverted internal limiting membrane flap technique in group A, and 29 cases(29 eyes)received PPV combined with internal limiting membrane peeling in group B. The patients were followed up for 6mo. The two groups were compared in terms of the hole closure rate, the reduction rate of retinal detachment and best corrected visual acuity(BCVA)before operation and at 1wk, 1, 3 and 6mo after operation, and the postoperative complications were recorded.RESULTS: The hole closure rate within 6mo after operation was significantly higher in group A than in group B(P&#x0026;#x003C;0.05), but there was no statistically significant difference in the reduction rate of retinal detachment(P&#x0026;#x003E;0.05). The BCVA of the two groups was significantly improved over time after operation(P&#x0026;#x003C;0.05). There was no statistically significant difference in BCVA between the two groups before operation and at 1wk, 1, 3 and 6mo after operation(P&#x0026;#x003E;0.05). Complications were observed in the two groups, but there was no statistically significant difference in the incidence of complications between the two groups(P&#x0026;#x003C;0.05).CONCLUSION: PPV combined with inverted internal limiting membrane flap technique is safe and effective in the treatment of MHRD in high myopia, which can effectively improve the patients' BCVA and the hole closure rate without influence on intraocular pressure.

Visual improvement and regeneration of retinal layers in eyes with small, medium, and large idiopathic full-thickness macular holes treated with the inverted internal limiting membrane flap technique over a period of 12 months.

PURPOSE: This study aims to compare the improvement of best-corrected visual acuity (BCVA) and the reduction in defect length of external limiting membrane (ELM) and ellipsoid zone (EZ) in small ([Formula: see text] 250 µm), medium ([Formula: see text] 250 µm), and large ([Formula: see text] 400 µm) full-thickness macular holes (FTMH) treated with inverted internal limiting membrane (I-ILM) flap technique over a follow-up period of 12 months. METHODS: Ninety-one eyes of 87 patients were enrolled in this retrospective study. BCVA and spectral-domain optical coherence tomography (SD-OCT) were conducted preoperatively as well as after 1, 3, 6, 9, and 12 months postoperatively. The defect length of the ELM and the EZ was measured using the caliper tool at each follow-up time point. RESULTS: BCVA improved significantly in the group of small, medium, and large FTMH over the time of 12 months, whereby the improvement did not depend on FTMH size over 9 months. Only after 12 months, large FTMH showed significantly higher BCVA improvement compared to small and medium FTMH. The closure rate was 100% (91/91). The defect length of ELM and EZ reduced continuously over the period of 12 months. There was a significant correlation between defect length of ELM and EZ with postoperative BCVA. CONCLUSION: The I-ILM flap technique has very good morphological and functional outcomes in small, medium, and large FTMH over a long-time period, indicating that it can be considered as a treatment option in small and medium FTMH. The defect length of ELM and EZ is directly connected to postoperative BCVA.

A case of Nd:YAG laser-induced traumatic macular hole with good visual prognosis after vitrectomy with inverted internal limiting membrane technique.

PURPOSE: To report an accidental case of traumatic macular hole caused by Nd:YAG laser in a dermatology clinic. OBSERVATIONS: A 24-year-old woman sustained a laser injury to her right eye while practicing a dermatologic treatment using a Nd:YAG laser without wearing protective goggles. She noticed sudden-onset and progressing visual loss in her right eye and consulted an ophthalmologist 2 days after injury. The best-corrected visual acuity (BCVA) of her right eye decreased to 20/133. Fundus examination showed white parafoveal flecks with a central retinal hemorrhage and underlying serous retinal detachment. The retinal sensitivity in this lesion deteriorated. Two weeks later, a full-thickness macular hole (FTMH) developed in the affected eye. She was referred to Nagoya City University Hospital where the laser damage described was observed. The BCVA was 20/67. She underwent pars plana vitrectomy performed using the inverted internal limiting membrane (ILM) flap technique and gas tamponade. One week postoperatively, the FTMH closed, the BCVA in her right eye improved to 20/50, and the retinal sensitivity in the macular area mostly improved. The BCVA gradually improved and reached 20/25 9 months after the injury. CONCLUSIONS AND IMPORTANCE: Protective goggles must be worn when using an Nd:YAG laser in the laboratory or clinical setting. In the unfortunate event of a FTMH, early vitrectomy with an inverted ILM flap technique can be helpful to achieve a good visual prognosis.

Changes in retinal sensitivity following inverted internal limiting membrane flap technique for large macular holes.

PURPOSE: The aim of this study was to evaluate the effect of inverted internal limiting membrane (ILM) flap technique and measure the retinal sensitivity using microperimetry-1 (MP-1) test in patients with large macular hole (MH). MATERIALS AND METHODS: We enrolled patients undergoing surgery for idiopathic MHs from January 2016 to October 2019. Only patients having a minimum diameter of idiopathic MH exceeding 500 µm were included in this study. All patients underwent complete preoperative ophthalmologic examinations, optical coherence tomography (OCT), and best-corrected visual acuity (BCVA) measurements. Postoperative OCT and BCVA were evaluated at least 3 months postoperatively. In addition, these patients also received MP-1 pre- and postoperatively for retinal sensitivity measurement. RESULTS: Totally ten patients (ten eyes) were included for analysis. The mean retinal sensitivity within central 12° and 40° was statistically improved after surgery (P < 0.05). The number of absolute or relative scotoma (stimulus values ≤4 dB) within central 4° showed a significant reduction postoperatively. There was also a significant increase in visual acuity postoperatively. CONCLUSION: Patients with large MH have a great successful rate by receiving inverted ILM flap technique. In our study, all MHs of ten eyes were closed postoperatively. The results also demonstrated that ILM flap technique improves both the functional and anatomic outcomes.

Inverted Internal Limiting Membrane Flap Technique: Is It the Best Option for Macular Holes?

Surgical treatment is generally necessary to repair full-thickness macular holes (FTMH). Although vitrectomy with or without internal limiting membrane (ILM) peeling remains the standard surgical technique, the inverted ILM flap procedure has increasingly assumed a role in the primary surgical repair of FTMHs. Some vitreoretinal surgeons reserve this technique to treat large or myopic holes, whereas others use it routinely in all cases. This paper is a comprehensive review of the current scientific evidence on the anatomical and functional outcomes of the inverted ILM flap technique in the repair of macular holes, following the International Vitreomacular Traction Study (IVTS) group classification.

Inverted Internal Limiting Membrane Flap Technique versus Internal Limiting Membrane Peeling for Large Macular Holes: A Meta-Analysis of Randomized Controlled Trials.

BACKGROUND: Vitrectomy with internal limiting membrane (ILM) peeling is an effective surgical procedure for the treatment of macular holes (MHs). However, there is a possibility of poor postoperative anatomical closure with conventional ILM peeling for MHs larger than 400 µm. Therefore, a novel inverted ILM flap technique was developed for such cases. OBJECTIVES: This meta-analysis study was performed to evaluate and compare the anatomical and visual outcomes of the inverted ILM flap technique and ILM peeling in large MHs. METHODS: The Cochrane Library, PubMed, and Embase databases were searched to identify randomized controlled trials (RCTs). The trial eligibility and risk of bias were assessed according to Cochrane review methods. The primary outcome measures included MH closure rate and postoperative visual acuity (VA). Subgroup analysis of postoperative VA based on follow-up time was also conducted. Pooled odds ratios (ORs), weighted mean difference (WMD), and 95% confidence intervals (CIs) were calculated. Statistical analysis was performed using RevMan 5.3 software. RESULTS: Five RCTs with a total of 155 eyes in the inverted ILM flap group and 161 eyes in the ILM peeling group were included in this meta-analysis. Statistical meta-analysis revealed that the overall MH closure rate in the inverted ILM flap group was significantly higher than that in the ILM peeling group (OR = 3.10; 95% CI: 1.25-7.66; p = 0.01). The postoperative VA was significantly better in the inverted ILM flap group than the ILM peeling group (WMD = -0.14; 95% CI: -0.21 to -0.07; p = 0.0002). The subgroup meta-analysis indicated that the postoperative VA was significantly better in the inverted ILM flap group than the ILM peeling group (WMD = -0.17; 95% CI: -0.26 to -0.08; p = 0.0004) at the 3-month follow-up. However, no significant difference was observed between the 2 groups at the 6-month follow-up (WMD = -0.09; 95% CI: -0.20 to 0.02; p = 0.10). CONCLUSIONS: Vitrectomy with the inverted ILM flap technique showed a higher anatomical closure rate as well as visual gain - although only in the short term as no difference in visual recovery was found at the 6-month follow-up - than did ILM peeling in large MHs. The inverted ILM flap technique should be considered as a preferred and routine procedure for the treatment of patients with MHs larger than 400 µm.

Inverted internal limiting membrane flap technique in eyes with large idiopathic full-thickness macular hole: long-term functional and morphological outcomes.

PURPOSE: To investigate morphological and functional outcomes of the inverted internal limiting membrane (I-ILM) flap technique in large (≥ 400 µm) idiopathic full-thickness macular holes (FTMH) over a follow-up period of 12 months. METHODS: In this retrospective study, 55 eyes of 54 consecutive patients were enrolled. Best-corrected visual acuity (BCVA) and spectral-domain optical coherence tomography (SD-OCT, Heidelberg, Spectralis) were performed preoperatively as well as 1, 3, 6, 9, and 12 months postoperatively. Special focus was put on the reintegration of outer retinal layers and the different ILM flap appearances. RESULTS: FTMH closure rate was 100% (55/55). BCVA significantly improved over the follow-up period of 12 months from 0.98 ± 0.38 LogMAR preoperatively to 0.42 ± 0.33 LogMAR at 12 months postoperatively (p < 0.001). There was no significant correlation between the three different ILM flap appearances and BCVA. Better preoperative BCVA, complete restoration of the external limiting membrane (ELM), higher macular hole index (MHI), and smaller MH base diameter were associated with higher improvement of BCVA. CONCLUSION: Our study highlights the favorable morphological and functional outcomes of the I-ILM flap technique in the short as well as in the long term. While complete ELM restoration revealed to be an important factor for improvement in BCVA, the different postoperative ILM flap appearances seem not to be related to BCVA.

Evaluation of inner retinal dimples and internal limiting membrane flap configuration after temporal inverted ILM flap technique.

PURPOSE: To quantitatively evaluate structural changes associated with inner retinal dimples (IRDs) and qualitatively classify the internal limiting membrane (ILM) flap configuration after temporal inverted ILM flap technique using spectral domain optical coherence tomography (SD-OCT). METHODS: Twenty-three eyes of 23 patients with successfully closed idiopathic, large (>400 µm) macular hole were enrolled. Patients were treated with pars plana vitrectomy followed by temporal inverted ILM flap technique. A complete ophthalmologic examination including cross sectional and en face OCT in addition to multicolor blue reflectance imaging of confocal scanning laser ophthalmoscopy (cSLO) was performed preoperatively and at postoperative month-12. The location, number, depth, and width of the IRDs were analyzed using blue reflectance images of multicolor cSLO and en face OCT. The ILM flap is also classified as smooth, wrinkled, and folded with en face OCT. RESULTS: The mean number of IRDs visualized on en face OCT (n = 23.08 ± 22.05) was statistically significantly higher compared with multicolor cSLO blue reflectance module (5.91 ± 10.58; p < 0.001). The mean depth of IRDs measured on en face OCT was 8.08 ± 3.1 µm (3-14 µm) which referred to the nerve fiber layer. The final visual acuity was associated with neither ILM flap configuration (p = 0.408), nor number of the IRDs on en face OCT (p = 0.112). CONCLUSION: En face OCT is a novel imaging modality that offers improved visualization and accuracy in identifying the features of the IRDs and the ILM flap. Additionally, it provides clear visualization of the vitreoretinal interface to distinguish whether ILM was peeled or not in the initial surgery.

Inverted internal limiting membrane flap technique in the surgical treatment of macular holes: 8-year experience.

PURPOSE: To evaluate the ellipsoid zone (EZ) structural recovery, hole closure rate, and visual acuity improvement after inverted internal limiting membrane (ILM) flap technique. METHODS: Retrospective cohort of eyes affected by idiopathic macular holes (MH) that underwent pars plana vitrectomy combined with inverted ILM flap technique in a tertiary center, over an 8-year period (2011-2019). The main outcomes were the postoperative qualitative analysis of EZ structure on spectral-domain optical coherence tomography, hole closure rate, and best-corrected visual acuity (BCVA) improvement of ≥ 0.3 units in the logarithm of minimal angle of resolution (logMAR) scale. RESULTS: Our study included 76 eyes of 72 patients; 65% were female, with a mean age of 70 ± 8 years-old. Median (range) follow-up was 21 (3-92) months. Hole closure rate was 92%. Structural defects in EZ were observed in 66% of closed holes (EZ atrophy in 33%, EZ disruption in 22%, and EZ thinning in 11%). The mean final BCVA was 0.5 ± 0.4 logMAR (Snellen 20/63), but visual acuity improvement occurred in 80% of the eyes. Final BCVA was significantly worse in eyes with EZ atrophy compared with eyes with EZ disruption (0.75 vs. 0.36 logMAR, p = 0.004) and EZ thinning (0.75 vs. 0.32 logMAR, p = 0.015). In multivariate regression, minimum linear diameter (OR 1.01; IC 95% 1.01-1.02) independently predicted a final BCVA (logMAR) < 0.3 units. CONCLUSION: Inverted ILM flap technique provided a hole closure rate above 90%, similar to previous studies. Although the modest value of the final BCVA, a significant visual acuity improvement occurred in most eyes. Structural defects of EZ were found in more than half of closed MHs after surgery. Evidence of postoperative retinal atrophy was associated with a worse visual outcome.

Development of traumatic bilateral horseshoe-shaped macular tear without vitreous traction: Case report.

To report our findings in a case with bilateral horseshoe-shaped macular tears. Both eyes of a 68-year-old woman developed horseshoe-shaped macular tears in the absence of vitreous traction due to prior vitrectomy in one eye and a posterior vitreous detachment in the other eye. Vitrectomy with the inverted internal limiting membrane flap technique led to a successful closure of the macular tear bilaterally, and an improvement of her visual acuity in both eyes. The cause of horseshoe-shaped macular tear was most likely due to a retinal rupture from a blunt trauma.

Effects of inverted internal limiting membrane technique and insertion technique on outer retinal restoration associated with glial proliferation in large macular holes.

PURPOSE: To compare the effects of inverted internal limiting membrane (ILM) flap technique and ILM insertion technique for large macular hole (MH) on glial proliferation, retinal outer layer restoration, and visual function. METHODS: This retrospective, observational study included 25 eyes with large MH (minimum diameter, ≥ 400 µm) treated using the inverted ILM flap or insertion technique. The inverted flap group was defined as flipping the ILM upside down on the MH (13 eyes) and the insertion group as inserting multiple ILM layers into the MH (12 eyes). RESULTS: Glial proliferation in the photoreceptor layer at 1 month and the final visit was significantly less frequent in the inverted flap group than in the insertion group (61.5% vs. 100%, p = 0.039; 23.1% vs. 100%, p = 0.001). The mean postoperative external limiting membrane defect was 140.4 ± 286.2 µm in the inverted flap group, significantly narrower than that in the insertion group (364.6 ± 181.6 µm; p = 0.016). The mean postoperative ellipsoid zone defect was 235.3 ± 214.2 µm in the inverted flap group, which was almost significantly narrower than that in the insertion group (496.3 ± 445.6 µm; p = 0.068). The change in the best-corrected visual acuity was significantly better in the inverted flap group than that in the insertion group (+ 18.5 vs. + 9.0 letters). CONCLUSION: Compared with patients treated with the insertion technique, those treated with the inverted ILM flap technique had significantly less glial proliferation at the photoreceptor space, more preferable outer retinal formation, and better visual improvement.

Comparative efficacy evaluation of inverted internal limiting membrane flap technique and internal limiting membrane peeling in large macular holes: a systematic review and meta-analysis.

BACKGROUND: The purpose of this study was to compare the anatomical and visual outcomes of inverted internal limiting membrane (ILM) flap technique and internal limiting membrane peeling in large macular holes (MH). METHODS: Related studies were reviewed by searching electronic databases of Pubmed, Embase, Cochrane Library. We searched for articles that compared inverted ILM flap technique with ILM peeling for large MH (> 400 µm). Double-arm meta-analysis was performed for the primary end point that was the rate of MH closure, and the secondary end point was postoperative visual acuity (VA). Heterogeneity, publication bias, sensitivity analysis and subgroup analysis were conducted to guarantee the statistical power. RESULTS: This review included eight studies involving 593 eyes, 4 randomized control trials and 4 retrospective studies. After sensitivity analysis for eliminating the heterogeneity of primary outcome, the pooled data showed the rate of MH closure with inverted ILM flap technique group was statistically significantly higher than ILM peeling group (odds ratio (OR) = 3.95, 95% confidence interval (CI) = 1.89 to 8.27; P = 0.0003). At the follow-up duration of 3 months, postoperative VA was significantly better in the group of inverted ILM flap than ILM peeling (mean difference (MD) = - 0.16, 95% CI = - 0.23 to 0.09; P < 0.00001). However, there was no difference in visual outcomes between the two groups of different surgical treatments at relatively long-term follow-up over 6 months (MD = 0.01, 95% CI = - 0.12 to 0.15; P = 0.86). CONCLUSION: Vitrectomy with inverted ILM flap technique had a better anatomical outcome than ILM peeling. Flap technique also had a signifcant visual gain in the short term, but the limitations in visual recovery at a longer follow-up was found.

Pathogenesis and treatment progress of idiopathic macular hole / 国际眼科杂志(Guoji Yanke Zazhi)

@#Idiopathic macular hole(IMH)refers to a full-thickness tissue defect of the retinal neuroepithelial layer in the macular region without obvious etiology. At present, with the gradual deepening of the understanding of IMH and the continuous innovation and improvement of its treatment methods, its treatment technology has also matured and diversified. Studies have shown that early IMH with small diameter can be observed and followed up. The Ocriplasmin has been approved for use in patients with small to medium sized macular holes and vitreomacular adhesion(VMA); internal limiting membrane(ILM)removal can improve anatomical closure rate. However, for IMH with a diameter of less than 250μm, it is uncertain whether ILM removal is always required. This paper discusses the pathogenesis, stages, classification and current treatment of IMH. Based on the characteristics of IMH and patient differences, an evidence-based medicine method is proposed to select the best and most practical treatment plan for individual patients.

Inverted internal limiting membrane (ILM) flap technique for macular hole closure: patient selection and special considerations.

This paper reviews the current status of the newer inverted internal limiting membrane flap technique for macular hole surgery. It gives an overview of the importance of patient selection and special considerations along with variations in technique. It discusses the pathophysiology and how the technique has been an important addition in the armamentarium of vitreoretinal surgeons to attain better anatomical as well as functional results in challenging situations.

Foveal microstructure and visual outcomes of myopic macular hole surgery with or without the inverted internal limiting membrane flap technique.

PURPOSE: The aim of this study was to determine the effect of the inverted internal limiting membrane (ILM) flap technique on the macular hole (MH) closure and foveal microstructure recovery of patients with highly myopic MH. METHODS: Pars plana vitrectomy and gas tamponade with the inverted ILM flap technique (19 eyes) or with the ILM peeling technique (21 eyes) were performed in patients with highly myopic MH with or without retinal detachment. The rate of MH closure and retinal reattachment, the reconstructive anatomical change of the foveal microstructure and the best-corrected visual acuities (BCVA) of the two groups were compared. RESULTS: The anatomic closure rate was statistically significantly higher in the inverted group (100%) than in the peeling group (66.7%; p=0.009). All eyes with MH retinal detachment had successful retinal reattachment in these two groups. However, the rate of the external limiting membrane (ELM) and ellipsoid zone (EZ) (p=0.020), as well as gliosis (p=0.049) in macular area, detected by OCT, was significantly greater in the inverted group than in the peeling group. The postoperative BCVA was significantly better in the eyes with ELM, EZ (p=0.031) and gliosis (p=0.008), but without hyperreflective foci (p=0.001). CONCLUSIONS: These findings demonstrate that the inverted ILM flap technique has better efficacy than the ILM peeling technique for patients with myopic MH in closure rate, foveal microstructure and postoperative BCVA.

Perfluorocarbon liquid-assisted membrane staining and peeling technique for macular diseases.

PURPOSE: A surgical technique is described that facilitates membrane peeling in patients with macular diseases by using small amounts of perfluorocarbon liquid (PFCL) and brilliant blue G (BBG) dye. STUDY DESIGN: Retrospective cohort study. METHODS: After placing about 1.0-1.5 cc PFCL on the macular area, BBG was applied with a 27-gauge blunt needle at the interface of PFCL and retina. The membrane peeling was performed under PFCL. RESULTS: The amount of BBG dye with PFCL-assisted staining technique has the potential to be smaller than in conventional staining method. Since the displacement angle of the membrane during peeling procedures is considerably increased by PFCL, combined with its high specific gravity and interfacial tension, the risk of tearing the membrane during manipulation is reduced to a great extent. The postoperative visual function in patients with PFCL-assisted peeling was comparable to that of patients without PFCL-assisted peeling. CONCLUSION: The PFCL-assisted technique enables sufficient membrane staining with minimal amounts of BBG dye, with tearing of the epiretinal membrane or internal limiting membrane being less likely than with the conventional method.