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      Comparison of Internal Limiting Membrane Peeling and Flap Removal to Flap Insertion on Visual Outcomes in Highly Myopic Eyes with Macular-Hole Retinal Detachment


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          Introduction: To compare the morphological and visual outcomes after pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling and flap removal to that with flap insertion in eyes with myopic macular-hole retinal detachment (MHRD). Methods: Forty-six eyes of 45 patients with MHRD were studied. Eighteen eyes were treated by PPV with ILM peeling and flap removal and 28 eyes by flap insertion, respectively. The baseline characteristics and postoperative findings were compared between the 2 groups. Results: The average age of the cases was 70.0 ± 8.5 years. The best-corrected visual acuity (BCVA) improved, from 1.51 ± 0.14 to 1.31 ± 0.20 log<sub>MAR</sub> units in the flap removal group, and from 1.20 ± 0.10 to 0.88 ± 0.10 log<sub>MAR</sub> units in the flap insertion group ( p = 0.049). A significantly larger number of MHs were closed in the flap insertion group (96 vs. 50% in the removed group; p < 0.001). Restoration of the ellipsoid zone (EZ) and external limiting membrane (ELM) was also better in the flap insertion group than in the flap removal group (EZ 14 vs. 6%, p = 0.003; ELM 36 vs. 6%, p < 0.001). Discussion: The technique of ILM peeling with flap insertion is more effective in closing the MH, and results in better BCVA and better restoration of the outer retinal microstructures than flap removal.

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          Most cited references18

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          Inverted internal limiting membrane flap technique for large macular holes.

          Large macular holes usually have an increased risk of surgical failure. Up to 44% of large macular holes remain open after 1 surgery. Another 19% to 39% of macular holes are flat-open after surgery. Flat-open macular holes are associated with limited visual acuity. This article presents a modification of the standard macular hole surgery to improve functional and anatomic outcomes in patients with large macular holes. A prospective, randomized clinical trial. Patients with macular holes larger than 400 μm were included. In group 1, 51 eyes of 40 patients underwent standard 3-port pars plana vitrectomy with air. In group 2, 50 eyes of 46 patients underwent a modification of the standard technique, called the inverted internal limiting membrane (ILM) flap technique. In the inverted ILM flap technique, instead of completely removing the ILM after trypan blue staining, a remnant attached to the margins of the macular hole was left in place. This ILM remnant was then inverted upside-down to cover the macular hole. Fluid-air exchange was then performed. Spectral optical coherence tomography and clinical examination were performed before surgery and postoperatively at 1 week and 1, 3, 6, and 12 months. Visual acuity and postoperative macular hole closure. Preoperative mean visual acuity was 0.12 in group 1 and 0.078 in group 2. Macular hole closure was observed in 88% of patients in group 1 and in 98% of patients in group 2. A flat-hole roof with bare retinal pigment epithelium (flat-open) was observed in 19% of patients in group 1 and 2% of patients in group 2. Mean (or median) postoperative visual acuity 12 months after surgery was 0.17 (range, 0.1-0.6) in group 1 and 0.28 (range, 0.02-0.8) in group 2 (P = 0.001). The inverted ILM flap technique prevents the postoperative flat-open appearance of a macular hole and improves both the functional and anatomic outcomes of vitrectomy for macular holes with a diameter greater than 400 μm. Spectral optical coherence tomography after vitrectomy with the inverted ILM flap technique suggests improved foveal anatomy compared with the standard surgery. Copyright © 2010 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.
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            The Role of Inverted Internal Limiting Membrane Flap in Macular Hole Closure.

            To investigate the mechanism of macular hole (MH) closure following the inverted internal limiting membrane (ILM) technique.
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              Comparative analysis of large macular hole surgery using an internal limiting membrane insertion versus inverted flap technique

              To determine whether the internal limiting membrane (ILM) insertion technique is as effective as the inverted ILM flap technique for the initial surgical treatment of eyes with large idiopathic macular holes (MHs). This retrospective, non-randomised, comparative clinical study included 41 eyes with large MHs (minimum diameter >500 µm) that were treated using the ILM insertion technique or the inverted ILM flap technique. The hole closure rate, postoperative best corrected visual acuity (BCVA) and swept source optical coherence tomography findings were analysed at 6 months after surgery. There were 15 and 26 eyes in the insertion and inverted flap groups, respectively. Hole closure was achieved in all eyes. The mean final BCVA was better in the inverted flap group than in the insertion group (0.527 vs 0.773, p=0.006), although significant postoperative improvements were observed in both groups (p<0.001). Postoperative foveal discolouration was more common in the insertion group than in the inverted flap group (86.7% vs 7.7%, p<0.001). Complete resolution of ellipsoid zone and external limiting membrane defects was observed in 7 and 18 eyes, respectively, in the inverted flap group; in contrast, complete resolution was not observed in any of the eyes in the insertion group (p=0.035 and p<0.001, respectively). The ILM insertion technique may be as effective as the inverted ILM flap technique for the closure of large MHs. However, the latter technique results in better recovery of photoreceptor layers and, consequently, better postoperative visual acuity.

                Author and article information

                S. Karger AG
                May 2021
                15 July 2020
                : 244
                : 2
                : 110-117
                Department of Ophthalmology and Visual Science, Chiba University Graduate School of Medicine, Chiba, Japan
                Author notes
                *Takayuki Baba, MD, Department of Ophthalmology and Visual Science, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba 260-0856 (Japan), babatakayuki@nifty.com
                510150 Ophthalmologica 2021;244:110–117
                © 2020 S. Karger AG, Basel

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                : 23 April 2020
                : 07 July 2020
                Page count
                Figures: 2, Tables: 5, Pages: 8
                Research Article

                Vision sciences,Ophthalmology & Optometry,Pathology
                Internal limiting membrane,Macular hole,Retinal detachment,Optical coherence tomography,High myopia


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