Inverted Internal Limiting Membrane Flap Technique for Macular Hole Surgery Without Extra Manipulation of the Flap

Casini, Giovanni; Mura, Marco; Figus, Michele; Loiudice, Pasquale; Peiretti, Enrico; Cillà, Stefano De; Fuentes, Taiusha; Nasini, Francesco

doi:10.1097/iae.0000000000001470

Cited by 48 publications

(51 citation statements)

References 20 publications

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“…Alternative surgical techniques have been proposed, trying to improve the original procedure described by Michalewska et al Casini et al compared the classic ILM flap technique with a modified and shorter ILM flap technique: the ILM flap remains attached to the retina only to the edges of the MH, looking like a funnel with the narrow opening attached to the retina, and no extra manipulations of the flap were performed. Their results showed no significantly difference in anatomical and functional outcomes between these two techniques [15]. Rossi et al reported two surgical variations of the original ILM flap technique.…”

Section: Discussionmentioning

confidence: 96%

Inverted internal limiting membrane flap technique versus complete internal limiting membrane peeling in large macular hole surgery: a comparative study

et al. 2020

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Background: To compare the anatomical and functional outcomes of the inverted internal limiting membrane (ILM) flap technique and the complete ILM removal in the treatment of large stage 4 macular hole (MH) > 400 μm and to evaluate reconstructive anatomical changes in foveal microstructure using spectral-domain optical coherence tomography. Methods: This is a retrospective, consecutive, nonrandomized comparative study of patients affected by idiopathic, myopic or traumatic stage 4 MH (minimum diameter > 400 μm) treated with 25-gauge pars-plana vitrectomy with either complete ILM peeling (n = 23, Group 1) or inverted ILM flap technique (n = 23, Group 2), between August 2016 and August 2018. Main outcomes measured were the MH closure rate assessed by spectral-domain optical coherence tomography and the best-corrected visual acuity (BCVA) at six months. Foveal microstructure reconstructive changes were evaluated using SD-OCT to determine predictive factors of postoperative BCVA. Results: Closure of MH was achieved in 16/23 cases of Group 1 (70%) and in 22/23 cases of the Group 2 (96%). Surgical failure was reported in 6 cases of Group 1 and 1 case of Group 2. The MH closure rate was significantly higher with the inverted ILM flap technique (P-value = 0.02). Average BCVA (LogMAR) changed from 1.04 ± 0.32 to 0.70 ± 0.31 in Group 1 and from 0.98 ± 0.22 to 0.45 ± 0.25 in Group 2 (P-value = 0.005) at 6 months. Improvement in BCVA (> 0.3 LogMAR units) was statistically higher in the Group 2 (P-value = 0.03). Restoration of foveal microstructure was significantly higher in the Group 2 at 6 months (52% vs 9%, P-value < 0.01). In Group 2, the integrity of the external limiting membrane at 3 months postoperatively was the only significant feature correlated with postoperative BCVA at 6 months (r = 0.562; P-Value = 0.01, forward stepwise regression analysis). Conclusion: Inverted ILM flap technique is more effective than the classic ILM peeling for the closure of large stage 4 MHs > 400 μm, improving both anatomical and functional outcomes. Early recovery of the external limiting membrane at 3 months is a positive predictive value of postoperative BCVA 6 months after inverted ILM flap technique.

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Section: Discussionmentioning

confidence: 96%

Inverted internal limiting membrane flap technique versus complete internal limiting membrane peeling in large macular hole surgery: a comparative study

et al. 2020

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“…7 Casini et al investigated a modification to the inverted ILM flap technique, using the fluid-air exchange in place of surgical manipulation to invert the remaining attached ILM over the macular hole, and found similar success compared to the Michaelewska technique. 11 Flap displacement, however, remains a concern in the inverted ILM flap technique. Thus, we hypothesized that the orientation of the inverting flap (horizontal from temporal to nasal versus vertical from superior to inferior) could influence surgical outcomes.…”

Section: Introductionmentioning

confidence: 99%

<p>Comparison of Three Different Techniques of Inverted Internal Limiting Membrane Flap in Treatment of Large Idiopathic Full-Thickness Macular Hole</p>

Ghassemi¹,

Khojasteh²,

Khodabande³

et al. 2019

OPTH

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Purpose: To evaluate and compare three different techniques of inverted internal limiting membrane (ILM) flap in the treatment of large idiopathic full-thickness macular hole. Methods: In a comparative interventional case series, 72 eyes from 72 patients with large (> 400 µm) full-thickness macular hole were randomly enrolled into three different groups: group Ahemicircular ILM peel with temporally hinged inverted flap; group Bcircular ILM peel with temporally hinged inverted flap; and group Ccircular ILM peel with superior inverted flap. Best-corrected visual acuity (BCVA), anatomical closure rate, and ellipsoid zone (EZ) or external limiting membrane (ELM) defects were evaluated preoperatively, at week 1, and months 1, 3 and 6 after surgery. Results: There were 24 eyes in group A, 23 in group B, and 25 in group C. In all three groups, larger diameter macular hole was associated with worse preoperative visual acuity (r=0.625, P<0.001). Mean BCVA improved significantly in all three groups 6 months after surgery (0.91vs 0.55, p<0.001). 6 months after surgery, mean BCVA improved from 0.91 logMAR to 0.52±0.06 in group A, 0.90 to 0.53±0.06 in group B, and 0.91 to 0.55±0.11 in group C. In group A vs. B vs. C, improvement of BCVA was 0.380±0.04 vs. 0.383±0.04 vs. 0.368±0.11 logMAR, with no statistically significant difference between groups (P=0.660). The rate of successful hole closure was 87.5% vs. 91.3% vs. 100%. Although the closure rate was 100% in Group C (circular ILM peel with superiorly hinged inverted flap), this difference was not statistically significant (P=0.115). Conclusion: ILM peel with an inverted flap is a highly effective procedure for the treatment of large, full-thickness macular hole. Different flap techniques have comparable results, indicating that the technique can be chosen based on surgeon preference.

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“…For non-chronic macular holes, the technique of tucking ILM flap in the macular hole has been controversial [20]. It has been shown that ILM tucking as described by the Michalewska was not essential, and inverted flap without manipulation produced similar macular hole closure rate [21]. However, for chronic or recurrent macular holes, it would be difficult to conduct a similar randomized control trial, because of the low sample size.…”

Section: Discussionmentioning

confidence: 99%

Treatment of large, chronic and persistent macular hole with internal limiting membrane transposition and tuck technique

et al. 2020

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Background: Large, chronic full thickness macular holes which failed previous treatments are difficult to manage and even left untreated due to poor prognosis. A retrospective review of consecutive cases with chronic (at least 1 year) full thickness macular holes and internal limiting membrane (ILM) free flap transposition with tuck technique, after previously failed vitrectomy. Methods: This was a retrospective and interventional study conducted in a single centre by a single surgeon. Patients with full thickness macular hole for at least 1 year and at least one previously failed vitrectomy with ILM peeling were recruited. A 25G vitrectomy with ILM free flap transposition was done without assistance of PFCL, viscoelastic or autologous blood. The free flap was manually tucked into the macular hole free space and gas fluid exchange was performed with 20% SF6 as tamponade. The patients were postured prone for 2 weeks postoperatively. Best corrected visual acuity, macular hole duration, previous surgeries, optical coherence tomography (OCT) appearance, hole size and closure rate were recorded. Results: 8 consecutive patients were included from May 2016 to Feb 2018. Transposition surgery was performed an average of 1481 days (SD 1096) after diagnosis of macular hole and average of 1226 days (SD 1242) after first vitrectomy. Macular hole mean size was 821 μm (SD 361.3), preoperative VA was logMAR 1.038 (SD 0.19), postoperative VA was logMAR 0.69 (SD 0.19) at 3 months. There were 1.13 lines gained and a significant improvement of logMAR 0.33 (p = 0.0084) at 6 months. Hole closure was seen in 7 out of 8 eyes (87.5%). The OCT with failed closure showed ILM flap within a flat hole, however no overlying neurosensory layers was seen. The duration from diagnosis to surgery was 2349 days in this case. Conclusion: Free flap ILM transposition tuck without the use of additional intraoperative tamponade is an effective technique in treating large chronic macular holes with previously failed primary macular hole surgeries.

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Inverted Internal Limiting Membrane Flap Technique for Macular Hole Surgery Without Extra Manipulation of the Flap

Abstract: The macular hole closure rate, improved visual acuity, and no extra complications indicate noninferiority of the modified inverted ILM technique. Internal limiting membrane finishing, tucking, and massage may not be required to obtain surgical success.

Cited by 48 publications

References 20 publications

Inverted internal limiting membrane flap technique versus complete internal limiting membrane peeling in large macular hole surgery: a comparative study

Inverted internal limiting membrane flap technique versus complete internal limiting membrane peeling in large macular hole surgery: a comparative study

<p>Comparison of Three Different Techniques of Inverted Internal Limiting Membrane Flap in Treatment of Large Idiopathic Full-Thickness Macular Hole</p>

Treatment of large, chronic and persistent macular hole with internal limiting membrane transposition and tuck technique

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