Inverted Internal Limiting Membrane Flap Technique for Repair of Large Macular Holes

Abstract

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.

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

“…Both VA and mfERG response improved incrementally after surgery, but they do not adequately represent each other. 21 In our study, there is an increase in amplitude and a decrease in implicit time in group 2 postoperatively, but this was not statistically significant when compared to group 1. The improvement in mfERG takes a longer time than VA.…”

Closure of an Intraoperatively Enlarged Macular Hole by Revision Surgery with Free ILM Flaps

“…The improvement of BCVA has been reported in several studies and even improved mfERG responses have been previously described. These improvements are most possibly due, in part, to the functional regeneration and reconstruction of the photoreceptors [8] [9]. In our case, early postoperative SD-OCT findings did not present major changes until the final follow-up at six months after successful hole closure.…”

Inverted ILM flap, free ILM flap and conventional ILM peeling for large macular holes

“…The staining and removal of the ILM in cases of macular hole have been widely adopted and evolved since its original description in 1991 and it is considered by the majority of retinal specialist as the standard of care [ 23 – 25 ]. Despite no definitive evidence supporting a significant visual gain due to the sole action of removing the ILM; the evidence does suggest an increased rate of macular hole closure, decreased rate of reopening and decreased rate of reoperations [ 26 ].…”