Inverted Internal Limiting Membrane flap peeling technique for large macular holes: 6-month results

Purpose : to evaluate the clinical efficacy of Inverted Internal Limiting Membrane (ILM) flap technique for the treatment of large versus small macular holes. Methods : 30 eyes of 29 patients, who underwent 25-gauge pars plana vitrectomy (25G PPV) with Inverted Flap technique for a full-thickness macular hole, were included in this observational study and followed for median (interquartile range, IQR) of 24(8) weeks. Simultaneous cataract surgery was performed in 24 eyes. All eyes were divided into 2 groups according to hole size as found with OCT: Large Holes (LH) (>500 µm) and Small/Medium Holes (SMH) (<500 µm), 15 eyes each. A complete ophthalmological evaluation and OCT scans were performed at every follow-up visit. Hole closure day, detected by OCT, was recorded. Primary study outcome was the evaluation of differences in best corrected visual acuity (BCVA) change between the two groups; secondary outcomes were the evaluation of differences between the 2 groups in hole’s closing time and safety profile. Results : 20 eyes completed the 6-month follow-up. No significant differences between groups at baseline were reported, except for the median hole size (IQR), which was for LH and SMH (μm) 672(169) and 383(152), respectively (Fig 1-D). Primary macular hole closure was achieved in 100% and 93% of eyes in LH and SMH groups, respectively (Kaplan-Meyer survival curves followed by the log-rank test: p=0.4, Fig 1-C). In 1 patient an open flat hole (type 2 closure) was detected at the end of follow-up. Median BCVA (logMAR) in both groups improved significantly from baseline to week 4 (both groups: p=0.01), 8 (LH: p=0.003; SMH: p=0.02), 12 (LH: p=0.01; SMH: p=0.02), 16 (LH: p=0.01; SMH: p=0.02) and 24 (LH: p=0.04; SMH: p=0.02). Analysis between groups showed a significant difference in BCVA improvement only at 4 weeks (p=0.03), while no differences in intraocular pressure were found at each follow-up visit. OCT showed macular hole closure after a median time (IQR) of 22(22) and 16.5(12) days for LH and SMH, respectively (p=0.08). No serious adverse events were reported. Conclusions : 25G PPV with inverted ILM flap seems to be safe and effective for surgical treatment of either large or small macular holes, ensuring a fast closure and a significant visual recovery with no significant difference in closing time, irrespective of hole size.