Anatomical and Functional Outcomes in Eyes with Idiopathic Macular Holes that Underwent Surgery Using the Inverted Internal Limiting Membrane (ILM) Flap Technique Versus the Conventional ILM Peeling Technique

Abstract Purpose: To compare the anatomical, morphological, and functional outcomes of the conventional internal limiting membrane (ILM) peeling versus temporal inverted internal limiting membrane flap technique for large full-thickness macular holes (FTMHs). Subjects and Methods: Forty-six eyes of 44 patients with a minimum base diameter > 600 µm were included in this retrospective interventional study. The patients were divided into Group 1 (conventional ILM peeling) and Group 2 (temporal inverted ILM flap). 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 17/25 (68%) cases of Group 1 and 20/21 (95.2%) cases of Group 2. The hole closure rate was significantly higher in the temporal inverted ILM flap group (p = 0.022). The mean BCVA (logMAR) changed from 1.12 ± 0.43 to 0.72 ± 0.31 in Group 1 and from 1.07 ± 0.34 to 0.51 ± 0.26 in Group 2 at six months (p < 0.001 in both cases). U-shaped closure was observed in 3 (12%) eyes in Group 1 and 15 (71.4%) 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 = 0.009, p = 0.001, respectively).Conclusion: The temporal inverted ILM flap technique is more effective than conventional ILM peeling for larger than 600 µm macular holes and improves anatomical, morphological, and functional outcomes.

Download Full-text

Inverted internal limiting membrane flap technique versus internal limiting membrane peeling for large macular holes: A meta-analysis of randomized controlled trials

Ophthalmic Research ◽

10.1159/000515283 ◽

2021 ◽

Author(s):

Ji-Guo Yu ◽

Jing Wang ◽

Yi Xiang

Keyword(s):

Randomized Controlled Trials ◽

Meta Analysis ◽

Internal Limiting Membrane ◽

Controlled Trials ◽

Ilm Peeling ◽

Closure Rate ◽

Flap Technique ◽

Randomized Controlled ◽

Macular Holes

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 to 7.66; P = 0.01). The postoperative VA was significantly better in the inverted ILM flap group than 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 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 two groups at the 6-month follow-up (WMD, -0.09; 95% CI, -0.20 to 0.02; P = 0.10). Conclusions: Vitrectomy with 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.

Download Full-text

Outcomes of Inverted Internal Limiting Membrane Flap Technique for Large Idiopathic Macular Holes Surgery in Patients at A Tertiary Care Hospital

Journal of Nepal Medical Association ◽

10.31729/jnma.4393 ◽

2019 ◽

Vol 57 (217) ◽

Author(s):

Kiran Shakya ◽

Ram Prasad Pokhrel ◽

Om Krishna Malla

Keyword(s):

Visual Acuity ◽

Tertiary Care Hospital ◽

Tertiary Care ◽

Internal Limiting Membrane ◽

Care Hospital ◽

Base Diameter ◽

Flap Technique ◽

Macular Holes ◽

Idiopathic Macular Holes ◽

The Mean

Introduction: Large macular holes cause significant reduction in central visual acuity. The aim ofthe study is to find out short term anatomical and visual outcomes of inverted internal limitingmembrane flaps technique for large macular holes (base diameter>1000μm) surgery in patientsat a tertiary care hospital. Methods: A descriptive cross-sectional study was conducted in a tertiary care hospital fromJanuary 2018 to December 2018 after ethical clearance from the institutional review committee.The study was done in 12 patients with idiopathic macular holes (base diameter>1000μm), theywere repaired with 25 gauge pars plana vitrectomy with brilliant blue assisted large invertedinternal limiting membrane flap technique. Statistical analyses were performed using SPSS 19.0. Results: All twelve eyes had complete anatomical closure. Mean best corrected visualacuity preoperatively was 1.48 logMAR±0.246. The mean macular hole base diameter was1217.0±196.77μm. The mean age of patients was 68.75±4.97 years. Postoperatively,mean best corrected visual acuity was 0.978 logMAR±0.12. There were no postoperativecomplications. All the patients perceived decreased size of central scotoma. Conclusions: Inverted internal limiting membrane flaps for large macular holes is suitable methodfor closure of the very large hole, restoration of functional vision and decreased size of centralscotoma.

Download Full-text

Comparison of Anatomical and Visual Outcomes between Idiopathic and Myopic Macular Holes Using the Internal Limiting Membrane or Inverted Internal Limiting Membrane Flap Technique

Journal of Ophthalmology ◽

10.1155/2019/6723824 ◽

2019 ◽

Vol 2019 ◽

pp. 1-7 ◽

Cited By ~ 1

Author(s):

Federico Peralta Iturburu ◽

Claudia Garcia-Arumi ◽

Maria Bové Alvarez ◽

Jose Garcia-Arumi

Keyword(s):

Visual Acuity ◽

Macular Hole ◽

Small Sample Size ◽

Internal Limiting Membrane ◽

Small Sample ◽

Ilm Peeling ◽

Visual Outcomes ◽

Macular Holes ◽

Idiopathic Macular Holes

Purpose. To compare the results of vitrectomy with those of internal limiting membrane (ILM) peeling or inverted ILM flap for treating myopic or idiopathic macular hole. Methods. Thirty-nine eyes of 39 patients undergoing vitrectomy with ILM peeling for macular hole (25 idiopathic and 14 myopic) and 27 eyes of 27 patients undergoing vitrectomy with inverted ILM flap (15 idiopathic and 12 myopic) were included. Outcome measures were macular hole closure by optical coherence tomography and visual acuity at 6 months. Results. Closure was achieved in 25 (100%) idiopathic and 12 (86%) myopic macular holes in the ILM peeling group and in 14 (93%) idiopathic and 11 (91.77%) macular holes in the inverted ILM flap group. There were no statistically significant differences in restoration of the external limiting membrane and ellipsoid zone between the groups. Median best-corrected visual acuity (logarithm of minimal angle of resolution) at the end of follow-up was 0.22 (20/32 Snellen) in idiopathic and 0.4 (20/50) in myopic (P=0.042) patients in the ILM peeling group and 0.4 (20/50) in idiopathic and 0.4 (20/50) in myopic (P=0.652) patients in the inverted ILM flap group. Conclusion. Both techniques were associated with high closure rates in myopic and idiopathic macular holes, with somewhat better visual outcomes in idiopathic cases. The small sample size may have provided insufficient power to support the superiority of one technique over the other in the two groups.

Download Full-text

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

BMC Ophthalmology ◽

10.1186/s12886-019-1271-2 ◽

2020 ◽

Vol 20 (1) ◽

Cited By ~ 6

Author(s):

Yu Shen ◽

Xiaoqin Lin ◽

Luyi Zhang ◽

Miaoqin Wu

Keyword(s):

Sensitivity Analysis ◽

Meta Analysis ◽

Internal Limiting Membrane ◽

Ilm Peeling ◽

Internal Limiting Membrane Peeling ◽

Membrane Peeling ◽

Visual Outcomes ◽

Flap Technique ◽

Macular Holes

Abstract 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.

Download Full-text

Minimal internal limiting membrane peeling with ILM flap technique for idiopathic macular holes: a preliminary study

BMC Ophthalmology ◽

10.1186/s12886-020-01505-x ◽

2020 ◽

Vol 20 (1) ◽

Author(s):

Zizhong Hu ◽

Huiming Qian ◽

Silvia Fransisca ◽

Xunyi Gu ◽

Jiangdong Ji ◽

...

Keyword(s):

Internal Limiting Membrane ◽

Internal Limiting Membrane Peeling ◽

Membrane Peeling ◽

Flap Technique ◽

Macular Holes ◽

Idiopathic Macular Holes ◽

Preliminary Study

Download Full-text

A short term anatomical and visual outcomes of large idiopathic macular holes surgery following inverted internal limiting membrane flap technique

Nepalese Journal of Ophthalmology ◽

10.3126/nepjoph.v11i1.25414 ◽

2019 ◽

Vol 11 (1) ◽

pp. 29-32 ◽

Cited By ~ 1

Author(s):

Kiran Shakya ◽

Ram Prasad Pokharel ◽

Om Krishna Malla

Keyword(s):

Macular Hole ◽

Internal Limiting Membrane ◽

Hole Filling ◽

Flap Technique ◽

Macular Holes ◽

Snellen Chart ◽

Pars Plana ◽

Idiopathic Macular Holes ◽

The Mean

Introduction: Large macular holes are not uncommon among Nepalese women population causing severe visual problem. Objective: To evaluate the technique of inverted internal limiting membrane (ILM) flaps for the repairment of large macular holes. Methods: All 10 macular holes (diameter > 400 μm) were treated with pars planavitrectomy with inverted ILM flap technique. The procedure for macular hole surgerywas pars plana vitrectomy, posterior vitreous removal, internal limiting membrane(ILM) peeling with brilliant blue assisted, inverting ILM flap into macular hole, filling of the vitreous cavity with a gas bubble(C3 F8) and post-operative face-down positioning for 1 week. SD OCT images were taken preoperative and postoperative 1 month and 3 months follow up to assess the anatomical outcome of surgery and best corrected visual acuity (BCVA) was used to evaluate the functional outcome during each visit. The BCVA was recorded using the Snellen chart and was converted to the logarithm of the minimum angle of resolution (LogMAR) equivalents. Results: All 10 eyes had complete anatomical closure. The mean age of patients was 64.3 ± 7.53 years. The mean macular hole base diameter was 1039.4 μm (663-1526μm). Mean BVCA pre-operatively was 1.29 log MAR ±SD 0.25. Post-operatively, mean BCVA was 0.925 log MAR ±SD 0.143 (p= 0.002). There were no intra operative or post-operative complications. All the patients were followed up for a period of 3months. Conclusions: Inverted ILM flaps is effective for closure of the large macular hole and restoration of functional vision.

Download Full-text

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

10.21203/rs.2.14564/v2 ◽

2019 ◽

Author(s):

Yu Shen ◽

Xiaoqin Lin ◽

Luyi Zhang ◽

Miaoqin Wu

Keyword(s):

Sensitivity Analysis ◽

Meta Analysis ◽

Internal Limiting Membrane ◽

Ilm Peeling ◽

Internal Limiting Membrane Peeling ◽

Membrane Peeling ◽

Visual Outcomes ◽

Flap Technique ◽

Macular Holes

Abstract 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. Keywords: Inverted internal limiting membrane flap technique, Internal limiting membrane peeling, Large macular hole, Meta-analysis

Download Full-text

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

BMC Ophthalmology ◽

10.1186/s12886-019-1294-8 ◽

2020 ◽

Vol 20 (1) ◽

Cited By ~ 3

Author(s):

Prithvi Ramtohul ◽

Eric Parrat ◽

Danièle Denis ◽

Umberto Lorenzi

Keyword(s):

Optical Coherence Tomography ◽

Functional Outcomes ◽

Internal Limiting Membrane ◽

External Limiting Membrane ◽

Ilm Peeling ◽

Closure Rate ◽

Flap Technique ◽

Stage 4 ◽

Group 2 ◽

Group 1

Abstract 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.

Download Full-text

Effect of inverted internal limiting membrane flap technique on small-medium size macular holes

Scientific Reports ◽

10.1038/s41598-021-04739-x ◽

2022 ◽

Vol 12 (1) ◽

Author(s):

Kanako Yamada ◽

Akio Oishi ◽

Mao Kusano ◽

Hirofumi Kinoshita ◽

Eiko Tsuiki ◽

...

Keyword(s):

Visual Acuity ◽

Internal Limiting Membrane ◽

Medium Size ◽

External Limiting Membrane ◽

Ilm Peeling ◽

Closure Rate ◽

Postoperative Visual Acuity ◽

Flap Technique ◽

Macular Holes ◽

Significant Difference

AbstractInverted internal limiting membrane (ILM) flap technique was developed to achieve macular hole (MH) closure in large MH and refractory cases. In this study, we evaluate the effect of the technique for small-medium size MH. We recruited patients who underwent vitrectomy for small-medium size (< 400 μm) MH with either inverted ILM flap technique (flap group) or with conventional ILM peeling (peeling group). Using propensity score, 21 eyes of 21 patients in the peeling group were matched against 21 eyes of 21 patients in the flap group. We compared MH closure rate, postoperative visual acuity, and recovery of the external limiting membrane (ELM) and ellipsoid zone (EZ). The MH closure rate was not different between the two groups (flap vs peeling: 90% vs 100%, P = 0.49). Whereas there was no significant difference in visual acuity improvement between the two groups, the flap group showed more disruption of the ELM 3 months after surgery and of the EZ at 3 and 6 months after surgery (P = 0.02, P = 0.03, and P = 0.04, respectively). The result suggested that inverted ILM flap technique does not have additional benefits for small-medium size MHs and may delay recovery of retinal integrity.

Download Full-text