Inverted Internal Limiting Membrane Flap Technique for Extra Large Macular Holes

Aim: To investigate the outcome of the inverted Internal Limiting Membrane (ILM) flap technique for extra large idiopathic macular holes (MHs).Methods: A retrospective non-comparative surgical case series of seven eyes of 7 patients with MHs (base diameter of at least 1000 ?m) was conducted. All the MHs were treated using pars plana vitrectomy and brilliant blue G (BBG)-assisted inverted ILM flap technique. Spectral Domain- Optical Coherence Tomography (SD-OCT) images were used to assess the anatomical outcomes of surgery including the macular microstructure, while Best Corrected Snellen Visual Acuity (BCSVA) was used to evaluate the functional outcomes.Results: The average MH size was 1241microns and average symptom duration was nineteen months. All eyes achieved successful anatomical closure and there was no occurrence of a flat open type closure. SD-OCT microstructural study revealed a reconstruction of the Ellispod Zone (EZ) and External Limiting Membrane (ELM), in only 3 eyes. There was an improvement in visual acuity in 5 eyes, while 2 eyes maintained the same as pre operative vision. The largest increase in post operative visual acuity gain was a 4-line improvement in Best Corrected Snellen Visual Acuity (BCSVA) noted in one of the 3 eyes with reconstructed EZ and ELM. The 3 months symptom duration in this patient was the shortest in this series.Conclusion: Inverted ILM flap technique is a safe and effective approach for the management of extra large chronic idiopathic MHs with demonstrably good anatomical and limited functional results in a majority of cases. Postoperative reconstruction of the microstructure is however seen only in a minority of eyes. Despite an absence of the outer retina (EZ and ELM), some eyes still experience an improvement in vision. The symptom duration may play a vital role in functional outcome in this subset of extra large chronic MHs.

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Pedicle internal limiting membrane flap technique for very large macular holes: a preliminary report

International Journal of Retina and Vitreous ◽

10.1186/s40942-020-00248-7 ◽

2020 ◽

Vol 6 (1) ◽

Author(s):

José Edísio da Silva Tavares Neto ◽

Igor Neves Coelho ◽

Rodrigo Jorge ◽

David Leonardo Cruvinel Isaac ◽

Marcos Pereira de Ávila

Keyword(s):

Visual Acuity ◽

Macular Hole ◽

Case Series ◽

Internal Limiting Membrane ◽

Sao Paulo ◽

Functional Improvement ◽

São Paulo ◽

Flap Technique ◽

Macular Holes ◽

Linear Diameter

Abstract Background Conventional vitrectomy technique for macular hole surgery has a good outcome in small and medium macular holes, but for very large macular holes (minimum linear diameter higher than 700 μm) other techniques were developed aiming to achieve greater rates of closure and visual acuity gain. The purpose of this article is to report the anatomical and functional outcomes of four very large macular hole (MH) cases which have undergone vitrectomy with the pedicle internal limiting membrane (ILM) flap technique. Methods This is a retrospective series of four patients with large MH who were treated with vitrectomy and the pedicle ILM flap technique. Comprehensive ophthalmologic evaluation was performed before surgery and included ETDRS best-corrected visual acuity (BCVA) and spectral domain optical coherence tomography (SD-OCT) for MH measures: height, minimum linear diameter (MLD) and external base diameter. The particular detail of this technique is related to ILM flap creation. During the peeling, the ILM was not removed completely from the retina but was left attached to the edges of the macular hole and subsequently trimmed with the vitrectomy probe using the scissors mode. Results Four patients with very large MH underwent PPV and the pedicle ILM flap technique was used to pursue macular closure. Median preoperative BCVA was 20/400 (range: 20/320 to 20/400) and median postoperative BCVA was 20/200 (range: 20/320 to 20/200). Of the 4 cases reported, 3 obtained anatomical closure (75%), and also presented BCVA improvement after surgery, considering the last follow-up visit of each case. No additional procedures were performed in either case. One patient demonstrated no anatomic and functional improvement. Conclusion The present study describes the first Brazilian case series of very large MH treated by the inverted pedicle ILM flap technique. This technique was associated with anatomic and visual improvement in most cases, and represents an alternative therapeutic approach for large macular holes. Trial Registration Project registered in Plataforma Brasil with CAAE number 30163520.0.0000.5440 and approved in ethics committee from Ribeirão Preto Medical School Clinics Hospital, University of São Paulo—Ribeirão Preto, São Paulo, Brazil (appreciation number 3.948.426 gave the approval).

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The Role of Single-Layered Flap in Temporal Inverted Internal Limiting Membrane Flap Technique for Macular Holes: Pros and Cons

Journal of Ophthalmology ◽

10.1155/2019/5737083 ◽

2019 ◽

Vol 2019 ◽

pp. 1-8 ◽

Cited By ~ 2

Author(s):

Yasuyuki Takai ◽

Masaki Tanito ◽

Kazunobu Sugihara ◽

Akihiro Ohira

Keyword(s):

Internal Limiting Membrane ◽

Japanese Patients ◽

Symptom Duration ◽

Prone Positioning ◽

Flap Technique ◽

Macular Holes ◽

Pros And Cons ◽

Pars Plana ◽

Minimal Diameter

Purpose. To assess the safety and effectiveness of the single-layered inverted internal limiting membrane (ILM) flap technique for treating chronic, large, or highly myopic macular holes (MHs). Methods. The medical records of 20 eyes of 20 consecutive Japanese patients with large MHs n=6 (minimal diameter, >400 μm), chronic MHs n=2 (symptom duration, >24 months), MHs in high myopia n=11 (axial length, >26 mm), and MHs in a patient unable to maintain prone positioning postoperatively n=1 were reviewed retrospectively. All patients underwent 25-gauge pars plana vitrectomy and the temporal inverted ILM flap technique. A semicircular ILM notch was made temporally two disc diameters from the MH using a 25-gauge knife, and the ILM was peeled temporally to create a semicircular ILM flap using a 25-gauge forceps. The single-layered ILM flap was inverted in a nasal direction to cover the MH. When an epiretinal membrane (ERM) was present, it was peeled before the ILM flap was inverted. Results. The MHs closed successfully in all (100%) eyes postoperatively. In the MHs associated with an ERM, after hole closure, gradual foveal deformation occurred in both the area from which the ILM was not peeled and the ILM flap inverted side. Conclusions. The single-layered inverted ILM flap technique, a simple surgery to treat MHs, provides scaffolding for retinal gliosis and may facilitate bridge formation between the walls of the MH under the flap. Considering the 100% success rate of MH closure, this technique seems to be effective and safe for treating chronic, large, or highly myopic MHs and MHs in patients unable to maintain postoperative prone positioning. In the MHs associated with ERMs, gradual foveal deformation was observed after ERM peeling. Further studies are needed to minimize surgical complications and understand the mechanism of this technique. This trial is registered with UMIN000035091.

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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.

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Vitrectomy with the inverted internal limiting membrane flap technique in eyes with full-thickness macular hole and dry age-related macular degeneration

European Journal of Ophthalmology ◽

10.1177/1120672120921376 ◽

2020 ◽

pp. 112067212092137

Author(s):

Zofia Michalewska ◽

Jerzy Nawrocki

Keyword(s):

Visual Acuity ◽

Macular Degeneration ◽

Macular Hole ◽

Internal Limiting Membrane ◽

Age Related Macular Degeneration ◽

Full Thickness ◽

Flap Technique ◽

Age Related ◽

Macular Holes ◽

Full Thickness Macular Hole

Purpose To present effects of the inverted internal limiting membrane flap technique in full-thickness macular holes coexisting with dry age-related macular degeneration. Methods Our database was retrospectively reviewed in order to spot patients with the simultaneous diagnosis of dry age-related macular degeneration and full-thickness macular hole. Vitrectomy with the inverted internal limiting membrane flap technique was performed. Inclusion criteria were full-thickness macular hole, drusen, vitrectomy performed, and spectral domain optical coherence tomography (Copernicus HR, Optopol, Poland) or swept source optical coherence tomography (Triton, Topcon, Japan) before surgery, then 1 week (±3 days), 1 month (±1 week), 3 months (±1 month), 6 months (±1 month), 12 months (±2 months), and 18 months to 12 years after surgery. Main outcome measures Closure of macular hole and visual acuity at the final control. Results A total of 18 eyes of 12 patients (mean age: 68 years) were included. Mean minimum macular hole diameter was 493 μm. Mean maximum macular hole diameter was 1072 μm. Macular hole was closed in 16 eyes after first surgery and in all eyes after second surgery. Improvement of visual acuity was statistically significant ( P = 0.05), but there was no statistical significant correlation observed between initial macular hole diameters and final visual acuity ( P > 0.1). Conclusion The inverted internal limiting membrane flap technique improves anatomical and functional results in eyes with coexisting dry age-related macular degeneration and full-thickness macular holes. Final development of choroidal neovascularization or geographic atrophy is possible in rare cases.

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Combined Idiopathic Macular Hole Vitrectomy with Phacoemulsification without Face-Down Positioning

Journal of Ophthalmology ◽

10.1155/2012/571748 ◽

2012 ◽

Vol 2012 ◽

pp. 1-4 ◽

Cited By ~ 5

Author(s):

Fumihiko Yagi ◽

Seiji Takagi ◽

Goji Tomita

Keyword(s):

Visual Acuity ◽

Case Series ◽

Functional Results ◽

Idiopathic Macular Hole ◽

Closure Rate ◽

Postoperative Visual Acuity ◽

Macular Holes ◽

Idiopathic Macular Holes ◽

The Mean ◽

Final Closure

Purpose. To evaluate the outcome of combined vitrectomy with phacoemulsification without postoperative face-down positioning for idiopathic macular holes (MHs).Design. Retrospective, observational case series.Participants. Forty-two eyes of 42 patients with MH.Methods. We studied 42 eyes of 42 cases followed up for 6 months postoperatively. MH closure rate and preoperative and postoperative visual acuity (VA) were evaluated.Main Outcome Measures. MH closure rate and VA were evaluated after combined vitrectomy with phacoemulsification without postoperative face-down positioning.Results. Of the 42 holes, 40 (95.2%) were initially closed, and the final closure rate was 100%. Compared with preoperative VA, the mean VA was significantly improved at 1 month and the improvement was maintained for at least 6 months postoperatively.Conclusions. Combined vitrectomy with phacoemulsification without postoperative face-down positioning produced favorable anatomic and functional results for MH repair. Improvement in VA can be expected for up to at least 6 months postoperatively.

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Multifocal Electroretinography in Assessment of Macular Function after Internal Limiting Membrane Peeling in Macular Hole Surgery

Journal of Ophthalmology ◽

10.1155/2019/1939523 ◽

2019 ◽

Vol 2019 ◽

pp. 1-7

Author(s):

M. Y. Faria ◽

D. C. Sousa ◽

S. Mano ◽

R. Marques ◽

N. P. Ferreira ◽

...

Keyword(s):

Visual Acuity ◽

Macular Hole ◽

Functional Results ◽

Internal Limiting Membrane ◽

Multifocal Electroretinography ◽

Ilm Peeling ◽

Macular Hole Surgery ◽

Macular Function ◽

Retinal Layers ◽

Snellen Visual Acuity

Purpose. Internal limiting membrane (ILM) peeling is important for macular hole (MH) surgery but may have secondary effects visible on spectral domain optical coherence tomography (OCT) and multifocal electroretinography (mfERG). We relate integrity of inner and outer macular layers with functional results with mfERG. Methods. Nonrandomized prospective study of 33 consecutive eyes of 33 patients with macular hole who underwent vitrectomy with ILM peeling. Best-corrected visual acuity was assessed, and integrity of external layers was measured using OCT. Each component of mfERG, N1 and P1 amplitude and latency, was also measured. Results. All eyes showed macular hole closure. Visual acuity improved from 20/400 to 20/40 in the Snellen visual acuity chart (P<0.001), and OCT external lines were intact in 19 eyes and disrupted in 14 eyes. Postoperatively, N1 and P1 amplitudes in ring 1 increased compared to preoperative values (P<0.001 for both). Latency remained delayed for both N1 and P1 wave. In the group of 19 eyes with integrity of outer retinal layers, N1 amplitude in ring 1 was superior to the group of 14 patients with disrupted outer retinal layers (P=0.042). Conclusions. In macular hole surgery, structure analysis in OCT is one of the important outcomes for the retinal surgeon. Functional results are parallel with anatomic results, but visual gain is limited. The limited recovery in mfERG suggests an alteration of retinal physiology that could explain limited vision recover.

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Conventional internal limiting membrane peeling versus temporal inverted internal limiting membrane flap for large macular holes

European Journal of Ophthalmology ◽

10.1177/1120672119892427 ◽

2019 ◽

pp. 112067211989242 ◽

Cited By ~ 2

Author(s):

Remzi Avci ◽

Aysegul Mavi Yildiz ◽

Sami Yilmaz

Keyword(s):

Case Series ◽

Internal Limiting Membrane ◽

Internal Limiting Membrane Peeling ◽

Membrane Peeling ◽

Flap Technique ◽

Macular Holes ◽

Complete Restoration ◽

Group 2 ◽

Papillomacular Bundle ◽

Group 1

Purpose: To compare the functional, anatomical, and morphological results of conventional internal limiting membrane peeling versus temporal inverted internal limiting membrane flap technique for the treatment of macular holes larger than 400 μm. Design: Retrospective, comparative case series. Methods: A total of 33 patients were included, of whom 18 were treated with internal limiting membrane peeling (Group 1) and 15 were treated with temporal inverted internal limiting membrane flap technique (Group 2). Complete ophthalmic examination, such as microperimetry and optical coherence tomography, was performed preoperatively and at 12 months after surgery. Results: The closure rates accomplished in Groups 1 and 2 were 72.2% and 100%, respectively (p = 0.036). The mean improvement in best-corrected visual acuity was logMAR 0.49 ± 0.17 in Group 1 and logMAR 0.91 ± 0.15 in Group 2 (p = 0.037). U-shaped closure was achieved in one eye in Group 1 and 12 eyes in Group 2 (p < 0.001). Complete restoration of external limiting membrane and ellipsoid zone rates were significantly higher in Group 2 (p = 0.027 and p = 0.001, respectively). Conclusion: The single-layered temporal inverted internal limiting membrane flap technique improves not only anatomical and morphological but also functional outcomes of surgery for large macular holes. Furthermore, this technique seems to minimize the risk of iatrogenic trauma to the nasal part of the fovea and the corresponding papillomacular bundle fibers.

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Efficacy of inverted internal limiting membrane flap for large idiopathic macular holes

Pakistan Journal of Medical Sciences ◽

10.12669/pjms.35.2.689 ◽

2019 ◽

Vol 35 (2) ◽

Author(s):

Haroon Tayyab ◽

Asad Aslam Khan ◽

Sana Jahangir

Keyword(s):

Visual Acuity ◽

Macular Hole ◽

Internal Limiting Membrane ◽

Creative Commons ◽

Corrected Visual Acuity ◽

Macular Holes ◽

Idiopathic Macular Holes ◽

Best Corrected Visual Acuity ◽

Hole Closure ◽

Sd Oct

Objective: To evaluate the effectiveness of inverted internal limiting membrane flap in large idiopathic macular holes. Methods: Twelve patients diagnosed with idiopathic macular holes larger than 400um underwent 23 gauge Pars Plana Vitrectomy (PPV) with inverted internal limiting flap and gas tamponade at Al-Ehsan Eye Welfare Eye Hospital, Lahore from February 2017 to February 2018. All cases were diagnosed on Spectral Domain Optical Coherence Tomography (SD-OCT) and were followed up for 6 months. At every follow-up, best corrected visual acuity and SD-OCT was done. Results: We achieved macular hole closure in 91.6% (11/12) patients with idiopathic macular holes larger than 400um. Five out of 12 patients underwent combined phacoemulsification and PPV. One patient has flat hole closure which was considered failure. One patient was excluded from the study due to per-operative flap loss. This patient was not included in final data analysis of 12 patients. There was statistically significant gain in best corrected visual acuity after successful macular hole closure. We did not report any untoward events during or in the post-operative period. Conclusion: Inverted internal limiting flap is an effective method for repairing large macular holes. How to cite this:Tayyab H, Khan AA, Jahangir S. Efficacy of inverted internal limiting membrane flap for large idiopathic macular holes. Pak J Med Sci. 2019;35(2):---------. doi: https://doi.org/10.12669/pjms.35.2.689 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Surgical Treatment of Previously Unclosed Macular Holes

Ophthalmology in Russia ◽

10.18008/1816-5095-2020-3-368-374 ◽

2020 ◽

Vol 17 (3) ◽

pp. 368-374

Author(s):

R. R. Faizrakhmanov ◽

E. A. Larina ◽

O. A. Pavlovskii

Keyword(s):

Visual Acuity ◽

Surgical Treatment ◽

Macular Hole ◽

Free Flap ◽

Inverse Correlation ◽

Functional Results ◽

Internal Limiting Membrane ◽

Morphological Parameters ◽

Photoreceptor Layer ◽

Macular Holes

Macular holes are the most often pathology leading to reduced vision among persons after 60 years. The macular hole is the acquired disease which is a defect of a foveola part of retina on all thickness from an internal limiting membrane to an external segment of a photoreceptor layer. The standard method of treatment is surgery method: a microinvasive vitrectomy with membrane peeling in macular area. There is a number of the techniques increasing efficiency of operative intervention. Even in case of successful surgical intervention macular holes are not always closed.The purpose: development and assessment of morphological parameters of the central retina with a new surgical method of closing earlier operated macula hole using a free flap.Material and methods. 40 patients (40 eyes, 28 women and 12 men) had participated in this study. All patients were operated about macular hole with negative anatomic result. By technology which were used earlier, patients were divided into 3 studied groups (with PRP mass using, with introverted flap using, with mechanical matching of edges of a hole). The main method of research was the optical coherent tomography. All patients were operated by an original technique. It’s purpose was a closing of earlier operated rigid macular hole using a free flap.Results. The defect of a photoreceptor component was closed with an additional expansion of earlier created macular rexis in patients of the 1st and 3rd groups at reoperation. The earlier created flap of an internal limiting membrane was used in patients of the 2nd group. In the analysis of dependence of change of visual acuity from morphological parameters of a macular hole after primary surgical treatment the inverse correlation relation from diameter of a macular hole on small and big radiuses is revealed. The highest visual acuity after a reoperation was reached at patients of the second group.Conclusions. It is necessary to consider the technique which was used earlier, diameter of a macular hole on small and big radiuses, postoperative edema in a parafovea zone for planning the surgical treatment and a forecast of functional results.

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Spectral versus Time-Domain OCT in Detecting Preoperative Epiretinal Membranes that Accompany Macular Holes

European Journal of Ophthalmology ◽

10.5301/ejo.5000862 ◽

2016 ◽

Vol 27 (2) ◽

pp. 185-189

Author(s):

Prethy Rao ◽

Yoshihiro Yonekawa ◽

Benjamin J. Thomas ◽

Kimberly A. Drenser

Keyword(s):

Time Domain ◽

Case Series ◽

Internal Limiting Membrane ◽

Comprehensive Treatment ◽

Retrospective Case ◽

Epiretinal Membranes ◽

Macular Holes ◽

Pars Plana ◽

Time Domain Oct ◽

Sd Oct

Purpose To compare the sensitivities of spectral-domain optical coherence tomography (SD-OCT) versus time-domain OCT (TD-OCT) in identifying epiretinal membranes (ERM) preoperatively in patients who underwent surgery for full-thickness macular holes (FTMH). Methods This is an interventional retrospective case series of 59 eyes diagnosed with FTMHs who underwent 25-G pars plana vitrectomy with internal limiting membrane peeling between 2009 and 2015. Preoperative OCTs were obtained by SD-OCT (Spectralis, Heidelberg, Germany) or TD-OCT (Stratus, Carl Zeiss Meditec, Dublin, CA, USA). Volume scans were reviewed for ERM accompanying the FTMH. This was compared to indocyanine green-negative staining and intraoperative findings of ERM as the gold standard. Results Baseline characteristics between the SD-OCT and TD-OCT groups were comparable. Mean duration of postoperative follow-up was 41.4 weeks (±49.0). Of 59 eyes, 33 (55.9%) exhibited an ERM intraoperatively. Four ERMs (SD-OCT group) compared to 12 (TD-OCT group) were not visualized on preoperative OCT (p = 0.003). Sensitivity and specificity of SD-OCT in ERM detection was 79% and 100% compared to 14% and 91% for TD-OCT. Visual acuity improved in both arms (0.5 and 0.3 logMAR units in SD-OCT and TD-OCT, respectively (p = 0.002, 0.0002). Conclusions We found that SD-OCT was superior to TD-OCT in identifying the presence of ERM preoperatively in patients who underwent macular hole surgery. Since ERMs may decrease the chance of successful pharmacologic vitreolysis, we recommend using SD-OCT over TD-OCT in the evaluation of patients with FTMH to more accurately identify ERMs and allow more comprehensive treatment decisions (pharmacologic versus surgical).

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