Are Internal Limiting Membrane Flaps Necessary?

Macular hole surgery has evolved greatly from the original papers of Robert Wendell and colleagues in 1993. Now the options include different gases in various concentrations, whether to peel the ILM or not, and also when to incorporate ILM flaps to address macular holes.

Below is a case of a 67-year-old patient with a macular hole noted one month ago. The OCT demonstrates edema on the edge which has been shown to be a good prognostic sign without significant RPE atrophy.

What is your preferred method for hole closure in this patient?

A. Vitrectomy with ILM peeling?

B. Vitrectomy with ILM flap?

In a recent study by Rizzo and colleagues, a large series of patients were compared with and without ILM flap for primary macular holes. The study demonstrated a statistically significant higher closure rate in holes greater than 400 microns in size and in those with an axial length ≥26 mm using ILM flaps. Visual outcomes were equivalent in the patients in both groups who had closed holes. In another study by Manassa et al, the investigators prospectively enrolled patients with holes greater than 600 microns and found that overall closure rates were higher in those with an ILM flap and the type of closure (type 1) was seen in a higher percentage of those with ILM flap repairs. Creating flaps in macular hole surgery can be done in by various methods. There is the described method of a flap with placement of a viscoelastic tamponade to prevent movement. I reserve this for extremely large holes greater than 1000 microns in size or in cases of severe trauma. However, in more routine idiopathic macular hole cases, I typically peel the nasal ILM
first and then peel the temporal ILM to the edge of the hole. When completing the air fluid exchange, the hole settles nicely nasally covering the hole. A flex loop or diamond dusted eraser can be used to reposition the flap in case of dislocation under air.

The postoperative week 1 photo showed a closed hole by OCT in the type 1 configuration performed through intraocular gas.

Below is the surgical video for this patient.

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