title: Inverted internal limiting membrane flap technique for large macular holes.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  A prospective, randomized clinical trial.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
  
  
  METHODS
  Visual acuity and postoperative macular hole closure.
  
  
  RESULTS
  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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Klinika Okulistyczna Jasne Blonia, Lodz, Poland. zosia_n@yahoo.com
authors.forename: Zofia
authors.initials: Z
authors.lastname: Michalewska
authors.forename: Janusz
authors.initials: J
authors.lastname: Michalewski
authors.forename: Ron A
authors.initials: RA
authors.lastname: Adelman
authors.forename: Jerzy
authors.initials: J
authors.lastname: Nawrocki
mesh_terms: D000368:Aged; D001485:Basement Membrane / Q000601:surgery; D005260:Female; D005451:Fluorescein Angiography; D006801:Humans; D008297:Male; D013508:Ophthalmologic Surgical Procedures; D011446:Prospective Studies; D012167:Retinal Perforations / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D055213:Retinal Pigment Epithelium / Q000473:pathology; D013524:Surgical Flaps; D041623:Tomography, Optical Coherence; D014792:Visual Acuity / Q000502:physiology; D014821:Vitrectomy