PEDICLE TRANSPOSITION FLAP, INVERTED FLAP, FREE FLAP, AND STANDARD PEEL FOR LARGE FULL-THICKNESS MACULAR HOLES A Comparative Study

Purpose: To compare anatomical and functional outcomes of four different techniques for the treatment of large idiopathic full-thickness macular holes. Methods: This single-center retrospective study included 129 eyes of 126 patients with large (>500 mu m) full-thickness macular holes who presented between January 2018 and October 2022. All patients underwent 23/25 G vitrectomy and gas with standard internal limiting membrane (ILM) peel, pedicle transposition, inverted, or free flap technique. Postoperative optical coherence tomography images were assessed by two independent masked graders. Results: Mean age was 73.2 years (SD 8.4) with a median F/U of 5 months (IQR 8). The overall anatomical success rate was 81%; it was significantly lower (59%) for the standard ILM peel (P < 0.0001). The pedicle transposition flap showed superior visual recovery compared with the free flap (+27 vs. +12 ETDRS letters, P = 0.02). At 3 months, restoration of the external limiting membrane was significantly better for the pedicle transposition flap compared with free flap and standard ILM peel (P = 0.008 and P = 0.03) and superior to all the other techniques at 6 months (P = 0.02, P = 0.04, and P = 0.006). Conclusion: Standard ILM peel alone offers inferior outcomes for the management of large full-thickness macular holes. Of the alternative ILM techniques, despite similar closure rates, foveal microstructural recovery is most complete following the pedicle transposition flap and least complete following the free flap.