The Treatment of Large Macular Holes Using a Multi-layered Inverted Internal Limiting Membrane Flap Technique

Dong Hun Song; Myeong In Yeom; Jung Min Park

doi:10.3341/jkos.2018.59.5.428

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Song, Yeom, and Park: The Treatment of Large Macular Holes Using a Multi-layered Inverted Internal Limiting Membrane Flap Technique

Original Article

J Korean Ophthalmol Soc 2018;59(5):428-436.

Published online: 25 September 2018

DOI: https://doi.org/10.3341/jkos.2018.59.5.428

The Treatment of Large Macular Holes Using a Multi-layered Inverted Internal Limiting Membrane Flap Technique

Dong Hun Song, MD, Myeong In Yeom, MD, Jung Min Park, MD, PhD

Department of Ophthalmology, Maryknoll Medical Center, Busan, Korea

Address reprint requests to Jung Min Park, MD, PhD Department of Ophthalmology, Maryknoll Medical Center, #121 Junggu-ro, Jung-gu, Busan 48972, Korea Tel: 82-51-461-2540, Fax: 82-51-462-3534 E-mail: Pjm1438@hanmail.net

Received 30 November 2017 Revised 7 March 2018 Accepted 24 April 2018

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

To describe a multi-layered inverted internal limiting membrane (ILM) flap technique and to evaluate the surgical out-comes of this surgery in patients with macular holes > 800 μ m in base diameter.

Methods

The medical records of patients who received a multi-layered ILM flap technique were retrospectively studied and patients with macular holes > 800 μ m were included in the analyses. Best-corrected visual acuity (BCVA) before and after surgery, preoperative hole size, hole base size, vertical size, and hole closure after surgery were checked using spectral domain optical coherence tomography. Pars plana vitrectomy was performed and the ILM was stained using indocyanine green and peeled with the base attached at the hole margin. The ILM flap was inverted over the macular hole with 2∼3 layers, and gas injection was performed.

Results

The mean age of 12 patients was 65.2 ± 12.3 years. The mean BCVA (logMAR) was 1.27 ± 0.61. The mean hole size was 563.6 ± 221.9 μ m, the mean vertical size was 418.8 ± 80.9 μ m, and the mean hole base size was 1,182.8 ± 298.5 μ m. The mean follow-up period was 174.4 ± 143.3 days. Nine macular holes were closed after surgery but three macular holes were not closed. The postoperative mean BCVA (logMAR) was 0.21 ± 0.51. Eight eyes showed visual improvement while three eyes did not show visual improvement after macular hole surgery.

Conclusions

The macular hole was closed successfully and the visual acuity improved after the multi-layered, inverted ILM flap technique. The multi-layered, inverted ILM flap technique is therefore considered the treatment of choice for large macular holes.

Keywords: Inverted internal limiting membrane (ILM) flap technique, Large macular hole, Macular hole, Macular hole surgery, Multi-layered

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Figure 1.

Parameter of macular hole on optical coherence tomography. The macular hole diameters measured at the level of retinal pigment epithelium (BD), at the minimum extent of the hole (HD). The height of the hole (HT) was also measured. HT = height; HD = hole diameter; BD = base diameter.

Figure 2.

Schematic drawing showing multi-layered inverted internal limiting membrane (ILM) flap technique. (A) After performing a 23-gauge 3-port pars plana vitrectomy. (B) Indocyanine green (0.1% solution) is applied around the macular hole (MH). (C) The ILM is peeled off in a circular fashion around the MH. The ILM is not removed completely but left attached to the edge of the MH. (D) The ILM flap is flipped by inverting it using the intraocular forceps to cover the whole MH layer upon layer and gently massaged to make it flattened. Supplementary perfluorocarbon liquids is applied on top of the multi-layered inverted ILM flap as ballast before air-fluid exchange is performed.

Figure 3.

A case of full thickness macular hole in 70-year-old-female. Preoperative color fundus photography (A) and optical coherence tomography (OCT) (B) of the left eye demonstrated large macular hole (hole base: 1,436 μ m). 6 days after surgery, type 1 closure of hole was detected in OCT scan image (C). There was no change in logMAR vision from 1.10 to 1.10.

Figure 4.

A case of full thickness macular hole in 75-year-old-female. Preoperative color fundus photography (A) and optical coherence tomography (OCT) (B) of the left eye demonstrated large macular hole (hole base: 1,304 μ m). 7 days after surgery, type 1 closure of hole was detected in OCT scan image (C). logMAR vision improved from 1.60 to 1.00.

Figure 5.

A case of full thickness macular hole in 38-year-old-male. Preoperative color fundus photography (A) and optical coherence tomography (OCT) (B) of the left eye demonstrated large macular hole (hole base: 1,387 μ m). 13 days after surgery, type 1 closure of hole was detected in OCT scan image (C). logMAR vision improved from 1.20 to 0.70.

Figure 6.

A case of full thickness macular hole in 67-year-old-male. Preoperative color fundus photography (A) and optical coherence tomography (OCT) (B) of the right eye demonstrated large macular hole (hole base: 962 μ m). 2 months after surgery, type 1 closure of hole was detected in OCT scan image (C). logMAR vision improved from 0.80 to 0.70.

Figure 7.

A case of full thickness macular hole in 70-year-old-female. Preoperative color fundus photography (A) and optical coherence tomography (OCT) (B) of the right eye demonstrated large macular hole (hole base: 1,071 μ m). 14 days after surgery, type 1 closure of hole was detected in OCT scan image (C). logMAR vision improved from 0.80 to 0.70.

Table 1.

Characteristics of patients

Case	Sex	Age (years)	Laterality	Refractive error (D, SE)	Hole diameter (μ m)	Base diameter (μ m)	Hole height (μm)	Other ocular disorder
1	F	70	OS	2.50	908	1,436	393	Cataract
2	F	61	OD	1.25	331	830	265	Cataract
3	F	73	OD	1.50	394	890	266	Cataract
4	F	79	OS	1.00	318	1,163	442	Pseudophakia
5	F	49	OD	0.25	338	821	508	Pseudophakia
6	F	75	OS	−1.00	686	1,304	395	ERM, pseudophakia
7	M	55	OS	4.75	305	1,056	402	RRD (SO tamponade), ERM, pseudophakia
8	M	38	OS	0.50	610	1,387	498	RRD (s/p buckling), cataract, high myopia
9	M	67	OD	3.50	661	962	475	Cataract
10	F	68	OD	1.75	865	1,518	434	Cataract, ERM
11	M	77	OS	1.25	737	1,756	537	Pseudophakia
12	F	70	OS	−1.25	612	1,071	409	Cataract

SE = spherical equivalent; F= female; M = male; OD = oculus dexter; OS = oculus sinister; ERM = epiretinal membrane; RRD = rhegmatogenous retinal detachment; SO = silicone oil; s/p = status post.

Table 2.

Result of multi-layered inverted inverted internal limiting membrane flap technique

Case number	Follow up (days)	Baseline visual acuity (logMAR)	Postoperative visual acuity (logMAR)	Type of closure
1	423	1.10	1.10	Type 1 closure^*
2	448	1.00	0.30	Type 1 closure
3	228	1.00	0.10	Type 1 closure
4	63	3.00	1.10	Non-closure
5	210	1.00	0.50	Type 2 closure^†
6	67	1.60	1.00	Type 1 closure
7	115	1.00	1.00	Type 1 closure
8	58	1.20	0.70	Type 1 closure
9	73	0.80	0.70	Type 1 closure
10	59	1.00	1.30	Non-closure
11	122	0.80	0.80	Non-closure
12	123	1.00	1.00	Type 1 closure

^* Type 1 closure: Closed without foveal neurosensory retinal defect

^† Type 2 closure: Closed with foveal neurosensory retinal defect.

Table 3.

Result of the relation between hole size and hole closure

Result	N	Base diameter (μ m)		Hole diameter (μ m)
Result	N	Mean	Standard deviation	Mean	Standard deviation
Closure	9	1084.1	237.5	538.3	68.9
Non-closure	3	1479.0	298.4	640.0	165.2
Between 2 group comparision p-value^*		0.052		0.518

^* Mann-Whitney U-test.

Table 4.

Result of the relation between hole closure and visual acuity improvement

Result	Visual acuity improvement		Total
Result	Improve	No improve	Total
Closure	7	2	9
Non-closure	1	2	3
p-value^*	0.88		12

^* Chi-square test.

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