Closure of an Intraoperatively Enlarged Macular Hole by Revision Surgery with Free ILM Flaps

Introduction

Full-thickness large macular holes (with a diameter of > 400 µm) are associated with an increased risk of unsuccessful closure, even if state-of-the-art techniques, including internal limiting membrane (ILM) peeling and gas endotamponade, are used [1]. Successfully closed large macular holes often present as “flat-open” with an absence of neurosensory retina over the centrally preserved retinal pigment epithelium. Such “flat-open holes” have a limited functional outcome and higher risk of redetachment or reopening [2]. Since the description of the inverted “ILM flap” technique by Michalewska et al. [3], there have been case series reporting improved closure rates in eyes with a relatively poor prognosis, e.g., large refractory macular holes and macular holes in high myopia and after uveitis. Direct comparison of the “inverted ILM flap” technique with the classic ILM peeling-assisted pars-plana vitrectomy seems to support the favorable outcomes of the flap technique, reporting closure rates of 98% with ILM flap vs. 88% with ILM peeling [3], [4]. The introduction of the inverted ILM flap technique has improved closure rates. In the past years, several studies showed promising results regarding functional and anatomical outcome in cases of large and persistent macular holes, even with diameters up to 1000 µm. However, there is still very little data available in cases of macular holes with a diameter above 1000 µm in which category our case may serve as an important addition [5], [6].

Here we report a case of a large macular hole that was accidentally enlarged by retinal tissue loss during two consecutive surgical attempts to close the hole. Successful closure was finally achieved by the use of the free ILM flap technique.

^* Both authors contributed equally to this publication.

• References

• 1 Ullrich S, Haritoglou C, Gass C. et al. Macular hole size as a prognostic factor in macular hole surgery. Br J Ophthalmol 2002; 86: 390-393
• 2 Imai M, Iijima H, Gotoh T. et al. Optical coherence tomography of successfully repaired idiopathic macular holes. Am J Ophthalmol 1999; 128: 621-627
• 3 Michalewska Z, Michalewski J, Adelman RA. et al. Inverted internal limiting membrane flap technique for large macular holes. Ophthalmology 2010; 117: 2018-2025
• 4 Matsumura T, Takamura Y, Tomomatsu T. et al. Comparison of the inverted internal limiting membrane flap technique and the internal limiting membrane peeling for macular hole with retinal detachment. PLoS One 2016; 11: e0165068 doi:10.1371/journal.pone.0165068
• 5 Mahalingam P, Sambhav K. Surgical outcomes of inverted internal limiting membrane flap technique for large macular hole. Indian J Ophthalmol 2013; 61: 601-603 doi:10.4103/0301-4738.121090
• 6 Pires J, Nadal J, Gomes NL. Internal limiting membrane translocation for refractory macular holes. Br J Ophthalmol 2017; 101: 377-382
• 7 Kase S, Saito W, Mori S. et al. Clinical and histological evaluation of large macular hole surgery using the inverted internal limiting membrane flap technique. Clin Ophthalmol 2016; 11: 9-14 doi:10.2147/OPTH.S119762
• 8 Shanmugam MP, Ramanjulu R, Kumar M. et al. Inverted ILM peeling for idiopathic and other etiology macular holes. Indian J Ophthalmol 2014; 62: 898-899 doi:10.4103/0301-4738.141077
• 9 Chen Z, Zhao C, Ye JJ. et al. Inverted internal limiting membrane flap technique for repair of large macular holes: a short-term follow-up of anatomical and functional outcomes. Chin Med J 2016; 129: 511-517 doi:10.4103/0366-6999.176988
• 10 Hashimoto Y, Saito W, Fujiya A. et al. Changes in inner and outer retinal layer thicknesses after vitrectomy for idiopathic macular hole: implications for visual prognosis. PLoS One 2015; 10: e0135925