The Efficacy of Superior Inverted Internal Limiting Membrane Flap Technique for the Treatment of Full-Thickness Macular Hole

Vitrectomy for macular holes (MHs) has shown a high closure rate and evident vision improvement. 1-4 Many studies have shown that the removal of a membrane at the vitreoretinal interface in patients with idiopathic MH produced good functional and anatomical results. 4-7 Surgical treatment of MHs aims to relieve vitreofoveal traction because firm foveal vitreous adhesion, anteroposterior vitreomacular traction, and tangential traction are believed to be the main factors in the pathogenesis of MH.2 In 2010, Michalewska et al8 suggested an inverted internal limiting membrane (ILM) flap technique for the treatment of idiopathic large MH. This technique prevented the postoperative flat-open appearance of MHs and improved the functional and anatomical results for MHs with a large diameter (>400 μm).9 However, the spontaneous retroversion of the ILM flap, or even ILM flap loss, occurs in up to 14% to 20% of patients during fluid-air exchange. ).8,10 Moreover, the patients have to mostly lie face down after the surgery. Recently published studies have introduced a modification of the classic inverted ILM flap technique. 11,12 In this procedure, ILM peeling was restricted to the temporal side of the fovea, and the MH was covered with the temporal ILM flap. These studies concluded that the new technique was as effective as the classic inverted ILM flap technique for repairing large MHs. However, the temporal-side ILM flap could be difficult to keep in position because of the vector sum between gravity and the ILM tangential force. Therefore, in the present study, we attempted a novel modification by changing the direction of the ILM flap to the superior side to decrease the need of staying prone after the surgery for patients who had difficulty maintaining this position. We investigated the efficacy and convenience of the superior inverted ILM flap technique for the treatment of large idiopathic fullthickness MH. To our knowledge, this is the first study reporting the surgical outcome of this modified technique. © 2018 Lippincott Williams and Wilkins. All rights reserved.