New inverted ILM flap technique may improve outcomes in patients with large macular holes

This prospective study randomized 86 patients (101 eyes) with macular holes larger than 400 µm to standard 3-port pars plana vitrectomy with air or a modified technique in which a still-attached remnant of the internal limiting membrane (ILM) was inverted to cover the macular hole.

At 12 months postop, patients in the new technique group had better visual acuity (P = 0.001) and a 98 closure rate, compared to 88 percent with the standard procedure. The new technique also appeared to prevent the postoperative flat-open appearance of a macular hole, a condition that tends to reduce visual acuity outcomes.

A flat-hole roof with bare retinal pigment epithelium (flat-open) was observed in 19 percent of patients in the standard procedure group compared with 2 percent of patients in the new technique group. The respective mean (or median) visual acuity 12 months after surgery was 0.17 and 0.28 (P = 0.001).

In the first few months after macular hole surgery with the inverted ILM flap technique, SOCT demonstrated improvement in the foveal contour and increased tissue coverage of the macular hole.

The authors note an important limitation of this technique. The inverted ILM flap detached spontaneously during the fluid-air exchange in seven of 50 eyes, possibly because of the teaching curve of the new technique by the surgeon.