Multi-layer internal limiting membrane plug technique for management of large full-thickness macular holes (original) (raw)
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Effect of inverted internal limiting membrane flap technique on small-medium size macular holes
Scientific Reports, 2022
Inverted 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. A macular hole is characterized by a full thickness central foveal hole and causes metamorphopsia and vision loss. Since Kelly et al. 1 reported pars-plana vitrectomy (PPV) for treating macular holes (MHs) in 1991, it has become a standard treatment for MHs 2-6 . While the MH closure rate was improved with internal limiting membrane (ILM) peeling 7 , it was still suboptimal in large MHs 8 . In 2010, Michalewska et al. 9 reported the inverted ILM flap technique for large idiopathic MHs. The technique consists of partial peeling of the ILM and placing the flap over the MH. The authors reported that the technique increased the rate of complete MH closure to 98% for large idiopathic MHs (> 400 μm) compared with 88% with conventional PPV and ILM peeling. Although the inverted ILM flap technique was originally developed for large MHs, myopic MHs, and MH retinal detachment , the technique is sometimes used for small-medium size MHs . The risks and benefits of this approach have yet to be determined. In this study, the MH closure rate, postoperative best-corrected visual acuity (BCVA), and recovery of the external limiting membrane (ELM) and ellipsoid zone (EZ), which are closely associated with postoperative BCVA , were compared in the inverted ILM flap technique and conventional ILM peeling in small-medium size MHs. This was a retrospective, nonrandomized, comparative study. The study was approved by the Nagasaki University Hospital Clinical Research Ethics Committee and complied with the Declaration of Helsinki. Information about this study was made public, and patients were given the opportunity to refuse to participate in this study. The ethics committee waived the need for written informed consent. Patients who underwent vitrectomy for MH at Nagasaki University Hospital between July 2014 and October 2017 were recruited. Among the participants, patients whose minimum MH diameter was < 400 μm, full-thickness MH were included. Exclusion criteria were recurrent and secondary MHs, high myopia (axial length ≥ 27 mm), and MH with retinal detachment. Standard 3-port 25-gauge pars plana vitrectomy was performed with Constellation Vision System (Alcon Surgical, Ft. Worth, TX, USA). Triamcinolone acetonide was used to visualize the vitreous. Selection of inverted ILM
Spotlight on the Internal Limiting Membrane Technique for Macular Holes: Current Perspectives
Clinical Ophthalmology
Pars plana vitrectomy has become the standard procedure for primary macular holes (MHs) repair, including the removal of the posterior cortical vitreous, the stripping of eventual epiretinal membranes, and finally an intraocular gas tamponade. During this procedure, peeling the internal limiting membrane (ILM) has been proven to increase closure rates and avoid postoperative reopening in several researches. In fact, even in large MHs more than 400 µm, the advantage of peeling off the ILM was highlighted by better anatomical closure rates. Nevertheless, some authors suggested that ILM peeling is not always essential, because it generates various side effects in retinal structure and function. Furthermore, the ideal amount of ILM peeling and the most effective strategies for removing the ILM are still subject of research. Different surgical modifications have been reported as alternatives to traditional peeling in certain clinical settings, including ILM flaps, ILM scraping, and foveal sparing ILM peeling. As regards large MHs, the introduction of ILM inverted flap appeared as a game changer, offering a significantly higher >90% closure rate when compared to traditional ILM peeling. Modifications to inverted ILM flap procedures have been claimed in recent years, in order to define the best area and direction of ILM peeling and its correlation with functional outcomes. Moreover, several innovations saw the light in the setting of recurrent MHs, such as ILM free flap transposition, inverted ILM flap combined autologous blood clot technique, neurosensory retinal flap, and human amniotic membrane (HAM) plug, claiming higher anatomical success rate also in those complex settings. In conclusion, the aim of this review is to report how the success rate of contemporary macular surgery has grown since the turn of the century, especially for big and chronic MHs, analyzing in which way ILM management became a crucial point of this kind of surgery.
Graefes Archive for Clinical and Experimental Ophthalmology, 2022
Purpose To evaluate the surgical management, outcomes and prognostic factors of full thickness macular holes without residual internal limiting membrane (NO-ILM FTMHs). Methods We performed a multicenter, retrospective study of 116 NO-ILM FTMHs. Human amniotic membrane (hAM) plug, autologous ILM free flap transplantation (AILMT), and autologous retinal graft transplantation (ART) were performed in 58, 48, and 10 patients, respectively. Data were collected before and up to 12 months after surgery. The primary outcomes were hole closure and final best-corrected visual acuity (BCVA). Results The final BCVA (0.78 ± 0.51 logMAR) was significantly better than and correlated with the initial BCVA (p < 0.0001 and p = 0.004, respectively). Hole closure was achieved in 92% of eyes. The minimum FTMH diameter was wider and final BCVA was lower in the ART group than in the other groups (p < 0.003 and p < 0.001, respectively). FTMHs with diameter > 680 μm had a higher closure rate with hAM than with AILMT (p = 0.02). Conclusions AILMT and hAM were the most frequently performed surgeries with both high closure rate and significant functional improvement. Preoperative BCVA was correlated with final BCVA. The minimum FTMH diameter may guide the treatment choice.
Closing Macular Holes with “Macular Plug” Without Gas Tamponade and Postoperative Posturing
Retina, 2017
Purpose: To investigate the surgical results of macular hole surgery without gas tamponade or postoperative posturing in patients with Stage 3 and Stage 4 macular holes with $500 mm mean base diameter. Design: Retrospective interventional case series. Participants: Twenty-six patients with Stage 3 and Stage 4 macular holes. Methods: Twenty-six eyes of 26 patients with Stage 3 and Stage 4 macular holes and a mean base diameter of 892.8 ± 349 mm underwent pars plana 23-gauge vitrectomy with broad internal limiting membrane peel (ILM peel), inverted ILM flap repositioning (ILMR), and use of autologous gluconated blood clumps as a macular plug to close the macular hole. No fluid-air exchange, endotamponade, or postoperative posturing was used. The subjects were followed up for 12 months. The anatomical outcome of the procedure was evaluated by fundus examination and optical coherence tomography. Spectral domain optical coherence tomography was used to study the restoration of the outer retinal layer integrity in the postoperative period. The preoperative and postoperative best-corrected visual acuities in logMAR units were compared to evaluate functional outcome. Main Outcome Measure: Macular hole closure and best-corrected visual acuity before and after surgery. Results: Twenty-six patients with mean age 62.8 ± 7.3 years, preoperative median bestcorrected visual acuity 6/60 (1.0 logMAR units), and a mean base diameter of 892.8 ± 349 mm underwent surgery to close macular holes without gas tamponade or postoperative posturing. Twenty patients (76.9%) were phakic. Twenty eyes (76.92%) had Stage 3 macular holes and 6 eyes (23.10%) had Stage 4 macular holes. After a single surgery, hole closure was achieved in 100% of eyes. The median best-corrected visual acuity improved from 6/60 (1.0 logMAR units) to 6/18 (0.50 logMAR units) (P , 0.001). Three patients needed cataract surgery at 12-month follow-up. No major intraoperative or postoperative complications were observed. Conclusion: Twenty-three-gauge pars plana vitrectomy combined with broad ILM peeling, use of ILMR and autologous gluconated blood clumps as a macular plug is effective in achieving satisfactory hole closure with statically significant functional improvement for large Stage 3 and Stage 4 macular holes.
Inverted Internal Limiting Membrane Flap Technique for Large Macular Holes
Ophthalmology, 2010
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. Design: A prospective, randomized clinical trial. Participants: Patients with macular holes larger than 400 m 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.
Clin Ophthalmol, 2021
Purpose To evaluate anatomical and visual outcomes of pars plana vitrectomy (PPV) with internal limiting membrane peeling (ILMP) in large idiopathic full-thickness macular holes (FTMH). Predictive factors also formed part of the study. Patients and Methods A retrospective review of medical charts and optical coherence tomography images of patients with large idiopathic FTMH (≥400 µm) was conducted. Results One hundred and fifty-eight eyes of 155 patients with a mean age of 62.94±7.50 years were included in the study. Mean preoperative visual acuity (VA) was 1.26±0.36 logMAR. Mean preoperative minimum linear diameter (MLD) and basal linear diameter (BLD) were 644.89±136.85 µm and 1208.11±307.14 µm, respectively. At 12 weeks postoperative follow-up, FTMH closure rate was 61.39% and mean postoperative BCVA was 0.92±0.36 logMAR. Multivariate logistic regression analyses showed the anatomical outcome was significantly associated with BLD ≤1200 µm, preoperative vitreomacular interface (VM...
Journal of Ophthalmology, 2020
Purpose. To study the features in OCT-angiography and microperimetry in eyes with persistent full-thickness macular hole (FTMH) closed with the secondary plana vitrectomy (PPV) with autologous internal limiting membrane (ILM) plug. Methods. Secondary PPV was performed with closing the persistent FTMH with ILM plug, C3F8 tamponade, and face-down positioning. Four patients were followed for 6 months with best corrected visual acuity (BCVA) measurement, SD-OCT and OCT-A, and microperimetry. The results were compared with the fellow eye; in two patients, it was the healthy eye, and in two remaining eyes, successfully closed FTMH after primary PPV. Results. ILM flap was integrated in all cases with V-shape of closure, and atrophy was found in one case, with the largest diameter of FTMH. BCVA improved in two cases and remained the same in two cases. In OCT-A, the area of foveal avascular zone (FAZ) was larger, and foveal vessel density (FVDS) was smaller in eyes after secondary PPV in com...
Acta ophthalmologica, 2018
The purpose of this study was to compare the surgical outcomes of vitrectomy with conventional internal limiting membrane (C-ILM) peeling to that with the inverted ILM (I-ILM) flap technique for large macular holes (MHs). This was a retrospective chart review of consecutive cases with a large MH at nine hospitals in Japan. Among the 1342 eyes, 165 eyes of 165 cases met the inclusion criteria. The results for medium-large MHs with a diameter 400-550 μm were compared to that of eyes with an extra-large MH with a diameter >550 μm. In addition, the results of C-ILM peeling were compared to that of the I-ILM technique. In medium-large MHs, the closure rate was 95.2% (59/62) by C-ILM peeling and 100% (19/19) by the I-ILM technique. In extra-large MHs, the closure rate was 88.4% (38/43) by C-ILM peeling and 100% (41/41) by I-ILM. Although the difference between the two methods was not significant, the I-ILM technique was successful in 100% of the cases. Multiple logistic regression anal...
International Journal of Retina and Vitreous, 2020
Background Large, chronic full thickness macular holes which failed previous treatments are difficult to manage and even left untreated due to poor prognosis. A retrospective review of consecutive cases with chronic (at least 1 year) full thickness macular holes and internal limiting membrane (ILM) free flap transposition with tuck technique, after previously failed vitrectomy. Methods This was a retrospective and interventional study conducted in a single centre by a single surgeon. Patients with full thickness macular hole for at least 1 year and at least one previously failed vitrectomy with ILM peeling were recruited. A 25G vitrectomy with ILM free flap transposition was done without assistance of PFCL, viscoelastic or autologous blood. The free flap was manually tucked into the macular hole free space and gas fluid exchange was performed with 20% SF6 as tamponade. The patients were postured prone for 2 weeks postoperatively. Best corrected visual acuity, macular hole duration, ...
Journal of Nepal Medical Association, 2019
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 w...