Aug 2026· Journal of the Korean Ophthalmological Society· Vol 67, pp. 287-298· 0 citations· 24 references
TL;DR
In large macular holes, an extended ILM flap of approximately 1.5–3 DD improved anatomical stability and visual recovery, representing an effective surgical strategy, suggesting flap size modification may not be necessary for optimal results.
Abstract
Purpose: We evaluated the effect of internal limiting membrane (ILM) flap size on anatomical and functional outcomes of macular hole surgery, to determine the optimal flap size according to hole size.Methods: This retrospective study included 145 patients (147 eyes) with idiopathic full-thickness macular holes who underwent pars plana vitrectomy with ILM flap covering, followed for ≥6 months between January 2015 and August 2025 at a single center. Macular holes were classified as medium (250–400 μm) or large (400–800 μm) by minimum linear diameter. Patients were categorized by flap size into a standard group (≤1.5 disc diameters [DD]) and an extended group (>1.5–3 DD). Postoperative best-corrected visual acuity (BCVA), closure rate, foveal contour (U-, V-, or W-type), restoration of the external limiting membrane and ellipsoid zone, and complications were compared at 1 and 6 months.Results: In medium holes, both groups achieved 100% closure and comparable visual improvement, with no significant between- group differences. In large holes, the extended flap group showed greater BCVA improvement (ΔBCVA at 6 months, 0.49 vs. 0.12), higher closure rate (94.0% vs. 86.8%), more U-shaped foveal contours (48.0% vs. 13.2%), and higher external limiting membrane restoration (56.0% vs. 15.8%) than the standard group (p < 0.05). Multivariable analysis identified extended flap as an independent predictor of closure (adjusted OR, 6.77; 95% CI, 1.49–30.79; p = 0.013) and external limiting membrane restoration (adjusted OR, 10.42; 95% CI, 2.77–39.15; p = 0.001).Conclusions: In large macular holes, an extended ILM flap of approximately 1.5–3 DD improved anatomical stability and visual recovery, representing an effective surgical strategy. In medium holes, the standard flap achieved comparable outcomes, suggesting flap size modification may not be necessary for optimal results.
Larger hole dimensions were associated with poorer visual prognosis, whereas greater HH was associated with anatomical closure, and flap-assisted ILM techniques may improve anatomical success in TMH surgery.
S. Ozcalıskan, M. Ozbek, Anıl Korkmaz et al.· Journal of Clinical Medicine· 0 citations
Full-thickness macular holes (FTMHs) larger than 400 μm remain a surgical challenge with suboptimal closure rates when treated with conventional internal limiting membrane (ILM) peeling. The temporal inverted ILM flap technique has emerged as a promising alternative, yet direct comparisons-particularly regarding hole size specific outcomes and outer retinal microstructural recovery-remain scarce. This study aimed to compare the functional, anatomical, and morphological outcomes of these two surgical approaches.
This retrospective study included 32 patients with large idiopathic FTMHs (> 400 μm) who underwent surgery between 2020 and 2024. Patients were divided into two groups: conventional ILM peeling (Group 1,
n
= 16) and temporal inverted ILM flap technique (Group 2,
n
= 16). All procedures were performed by a single experienced surgeon. Best-corrected visual acuity (BCVA), MH closure rate, closure configuration, diameter hole index (DHI), and outer retinal layer parameters including ellipsoid zone (EZ) and external limiting membrane (ELM) integrity were assessed using spectral-domain optical coherence tomography (SD-OCT) at baseline and 12 months postoperatively.
Baseline characteristics did not differ significantly between the groups (all
p
> 0.05). Both groups showed significant improvement in BCVA after surgery (both
p
< 0.05). At 12 months, postoperative BCVA was 0.71 ± 0.46 logMAR in Group 1 and 0.38 ± 0.32 logMAR in Group 2, with significantly better BCVA in Group 2 (
p
= 0.039). Primary closure was achieved in 75.0% (12/16) of eyes in Group 1 and 100% (16/16) in Group 2, although the overall difference was not statistically significant (
p
= 0.101). In an exploratory post hoc subgroup analysis of eyes with a minimum hole diameter ≥ 550 μm, primary closure occurred in 33.3% (2/6) of Group 1 eyes and 100% (8/8) of Group 2 eyes (
p
= 0.015); both groups achieved 100% closure in holes measuring 400–549 μm. Postoperative EZ defect size was 1028.62 ± 606.93 μm in Group 1 and 539.12 ± 618.09 μm in Group 2, with a significantly smaller defect size in Group 2 (
p
= 0.040).
In this retrospective, non-randomized cohort, the temporal inverted ILM flap technique was associated with better postoperative BCVA and a smaller postoperative EZ defect size than conventional ILM peeling. Although an exploratory post hoc subgroup analysis suggested a higher primary closure rate in Group 2 among eyes with a minimum hole diameter ≥ 550 μm, the overall closure-rate difference was not statistically significant, and the subgroup analysis was based on very small sample sizes. Further prospective studies with larger sample sizes are needed to confirm these findings.
Not applicable (retrospective study).
Purpose: The purpose of the study was to evaluate the anatomical and functional outcomes of the inverted internal limiting membrane (ILM) flap technique in patients with large macular holes (MHs) and identify independent prognostic factors that predict post-operative visual acuity. Methods: This retrospective study included 48 eyes of 48 patients who underwent pars plana vitrectomy and inverted ILM flap technique for idiopathic MHs ≥400 μm. Pre-operative and post-operative best-corrected visual acuity (BCVA), swept-source optical coherence tomography (SS-OCT) parameters, and various clinical factors were evaluated. Multivariate regression analysis was performed to identify independent prognostic factors for the post-operative BCVA. Results: The mean BCVA improved significantly from 1.27±0.41 logMAR preoperatively to 0.62±0.37 logMAR at 6 months postoperatively (p<0.001). U-shaped closure was associated with better BCVA than V-and W-shaped closures (p=0.001). Patients with symptom duration ≤6 months and complete post-operative restoration of the external limiting membrane (ELM) and ellipsoid zone demonstrated significantly better BCVA (p<0.01). Pre-operative BCVA (β=0.637, p<0.001) and MH index (MHI) (β=−0.261, p=0.029) were significant independent determinants of post-operative BCVA. Conclusion: The inverted ILM flap technique provides high anatomical closure rates and significant visual improvement in large MH surgery. Pre-operative BCVA and MHI were significant independent prognostic factors for post-operative visual outcomes. Structural SS-OCT parameters can be clinically useful in predicting post-operative functional outcomes
Güzide Akçay, Dilber Celik Yaprak, U. Kıvrak et al.· European Eye Research· 0 citations
Purpose
. To evaluate the anatomical and functional efficacy of a modified autologous retinal transplantation (ART) technique in the surgical treatment of large full-thickness macular holes (FTMH).
Material and Methods
. The study included 41 patients (42 eyes) with a minimum FTMH diameter greater than 800 µm who had previously undergone vitrectomy with internal limiting membrane peeling and gas tamponade due to FTHM. Patients were divided into two groups. In the main group, a modified ART was performed using preoperative navigated flap planning, intraoperative optical coherence tomography guidance, and fixation with autologous platelet-rich plasma. In the control group, macular hole edges were closed using an aspiration technique followed by application of autologous platelet-rich plasma. Anatomical outcomes were assessed by optical coherence tomography, while functional outcomes included bestcorrected visual acuity and central retinal sensitivity. The follow-up period was 6 months.
Results
. Stable anatomical closure of the FTMH was achieved in all cases in the main group. In the control group, macular hole recurrence was observed in 22 % of patients (p = 0.049). Both groups demonstrated a statistically significant improvement in best-corrected visual acuity and retinal sensitivity as early as 1 month postoperatively, with no significant intergroup differences in cases with successful anatomical closure.
Conclusions
. Modified ART provides a higher and more stable anatomical success rate in the treatment of large FTMH compared with the edge approximation technique. Functional outcomes are characterized by early improvement followed by stabilization during follow-up.
D. Petrachkov, K. V. Baryshev, A. G. Matyuschenko et al.· Ophthalmology in Russia· 0 citations
PURPOSE
To report the feasibility, anatomical closure, and visual outcomes after a tamponade-free, perfluorocarbon liquid (PFCL)-free, viscoelastic-assisted superior internal limiting membrane (ILM) flap technique for idiopathic full-thickness macular holes (FTMH).
METHODS
Prospective, non-comparative pilot study of consecutive adults with idiopathic FTMH undergoing 25-gauge pars plana vitrectomy, superior ILM flap creation and intraoperative stabilization with dispersive viscoelastic. No PFCL, gas, or air tamponade was used, and no face-down positioning was required. Minimum follow-up was 3 months.
RESULTS
Twenty-six patients, fifteen women (57.7%) and eleven men (42.3%) were included in the study. The mean age was 72.2 ± 8.5 years (range 51-88). Mean minimum linear diameter (MLD) was 341.2 ± 191.8 μm (range 50-775 μm); 9 holes were small (< 250 μm), 10 were medium (250-400 μm), and 7 were large (> 400 μm). The mean duration of symptoms was 4.85 ± 3.34 months. Primary anatomical closure after one procedure occurred in 25/26 cases (96.2% primary success). The mean follow-up was 4.77 ± 1.37 months. Best-corrected visual acuity improved significantly (from 1.12 logMAR, to 0.46 logMAR, p < 0.001). Two intraoperative retinal tears occurred during posterior vitreous detachment (PVD) induction and were treated with endolaser; no postoperative retinal detachment, hypotony, or endophthalmitis occurred.
CONCLUSION
In this prospective pilot series, a PFCL-free, tamponade/air-free, viscoelastic-assisted superior ILM flap technique was associated with a high primary closure rate without postoperative positioning. Larger comparative studies with longer follow-up are needed to assess generalizability and complication rates, particularly for large macular holes.
Androniki Zampogianni, Stergios Ntikos, Nikolaos Moraitis et al.· Graefe's archive for clinica...· 0 citations
Postoperative restoration of the foveal pit is strongly associated with superior BCVA gain and CMT reduction, highlighting foveal morphology as a key prognostic marker for surgical success.
Aydın Maçin, Didem Serin· Zeynep Kamil Medical Journal· 0 citations
