J Korean Ophthalmol Soc.  2018 May;59(5):428-436. 10.3341/jkos.2018.59.5.428.

The Treatment of Large Macular Holes Using a Multi-layered Inverted Internal Limiting Membrane Flap Technique

• Song DH
• Yeom MI
• Park JM

• KMID: 2411451
• DOI: http://doi.org/10.3341/jkos.2018.59.5.428

Abstract

PURPOSE
To describe a multi-layered inverted internal limiting membrane (ILM) flap technique and to evaluate the surgical outcomes of this surgery in patients with macular holes > 800 µm in base diameter.
METHODS
The medical records of patients who received a multi-layered ILM flap technique were retrospectively studied and patients with macular holes > 800 µm were included in the analyses. Best-corrected visual acuity (BCVA) before and after surgery, preoperative hole size, hole base size, vertical size, and hole closure after surgery were checked using spectral domain optical coherence tomography. Pars plana vitrectomy was performed and the ILM was stained using indocyanine green and peeled with the base attached at the hole margin. The ILM flap was inverted over the macular hole with 2~3 layers, and gas injection was performed.
RESULTS
The mean age of 12 patients was 65.2 ± 12.3 years. The mean BCVA (logMAR) was 1.27 ± 0.61. The mean hole size was 563.6 ± 221.9 µm, the mean vertical size was 418.8 ± 80.9 µm, and the mean hole base size was 1,182.8 ± 298.5 µm. The mean follow-up period was 174.4 ± 143.3 days. Nine macular holes were closed after surgery but three macular holes were not closed. The postoperative mean BCVA (logMAR) was 0.21 ± 0.51. Eight eyes showed visual improvement while three eyes did not show visual improvement after macular hole surgery.
CONCLUSIONS
The macular hole was closed successfully and the visual acuity improved after the multi-layered, inverted ILM flap technique. The multi-layered, inverted ILM flap technique is therefore considered the treatment of choice for large macular holes.

Keyword

Inverted internal limiting membrane (ILM) flap technique; Large macular hole; Macular hole; Macular hole surgery; Multi-layered

MeSH Terms

Follow-Up Studies
Humans
Indocyanine Green
Medical Records
Membranes*
Retinal Perforations*
Retrospective Studies
Tomography, Optical Coherence
Visual Acuity
Vitrectomy
Indocyanine Green

Figure

• 

  Figure 1. Parameter of macular hole on optical coherence tomography. The macular hole diameters measured at the level of retinal pigment epithelium (BD), at the minimum extent of the hole (HD). The height of the hole (HT) was also measured. HT = height; HD = hole diameter; BD = base diameter.

• 

  Figure 2. Schematic drawing showing multi-layered inverted internal limiting membrane (ILM) flap technique. (A) After performing a 23-gauge 3-port pars plana vitrectomy. (B) Indocyanine green (0.1% solution) is applied around the macular hole (MH). (C) The ILM is peeled off in a circular fashion around the MH. The ILM is not removed completely but left attached to the edge of the MH. (D) The ILM flap is flipped by inverting it using the intraocular forceps to cover the whole MH layer upon layer and gently massaged to make it flattened. Supplementary perfluorocarbon liquids is applied on top of the multi-layered inverted ILM flap as ballast before air-fluid exchange is performed.

• 

  Figure 3. A case of full thickness macular hole in 70-year-old-female. Preoperative color fundus photography (A) and optical coherence tomography (OCT) (B) of the left eye demonstrated large macular hole (hole base: 1,436 μ m). 6 days after surgery, type 1 closure of hole was detected in OCT scan image (C). There was no change in logMAR vision from 1.10 to 1.10.

• 

  Figure 4. A case of full thickness macular hole in 75-year-old-female. Preoperative color fundus photography (A) and optical coherence tomography (OCT) (B) of the left eye demonstrated large macular hole (hole base: 1,304 μ m). 7 days after surgery, type 1 closure of hole was detected in OCT scan image (C). logMAR vision improved from 1.60 to 1.00.

• 

  Figure 5. A case of full thickness macular hole in 38-year-old-male. Preoperative color fundus photography (A) and optical coherence tomography (OCT) (B) of the left eye demonstrated large macular hole (hole base: 1,387 μ m). 13 days after surgery, type 1 closure of hole was detected in OCT scan image (C). logMAR vision improved from 1.20 to 0.70.

• 

  Figure 6. A case of full thickness macular hole in 67-year-old-male. Preoperative color fundus photography (A) and optical coherence tomography (OCT) (B) of the right eye demonstrated large macular hole (hole base: 962 μ m). 2 months after surgery, type 1 closure of hole was detected in OCT scan image (C). logMAR vision improved from 0.80 to 0.70.

• 

  Figure 7. A case of full thickness macular hole in 70-year-old-female. Preoperative color fundus photography (A) and optical coherence tomography (OCT) (B) of the right eye demonstrated large macular hole (hole base: 1,071 μ m). 14 days after surgery, type 1 closure of hole was detected in OCT scan image (C). logMAR vision improved from 0.80 to 0.70.

Reference

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