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Inverted ILM flap technique closes large macular holes
An inverted internal limiting membrane flap technique for the treatment of large macular holes offered a higher incidence of type 1 closure with improved functional outcomes compared with the standard internal limiting membrane peel, according to a study.
The prospective, randomized study included 100 patients with idiopathic macular holes with minimum linear dimension of 600 µm or greater who were randomly assigned into two groups. Group 1 patients underwent standard internal limiting membrane (ILM) peel, and group 2 patients underwent inverted ILM flap technique. The researchers evaluated visual acuity and postoperative macular hole closure as the primary outcome measures.
Group 2 patients experienced significantly higher postoperative visual acuity gains at 1 month and 3 months compared with patients in group 1.
In group 1, 42 of 48 eyes experienced anatomical closure of the macular hole; 26 eyes experienced type 2 closure while 16 eyes experienced type 1 closure. In group 2, 41 of 43 eyes experienced anatomical macular hole closure; 14 eyes experienced type 2 closure and 27 eyes experienced type 1 closure. Mean visual acuity was significantly higher in patients with type 1 closure, and the type 1 closure rate in group 2 was significantly higher than in group 1. – by Robert Linnehan
Disclosures: The authors report no relevant financial disclosures.
Perspective
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Macular hole surgery has evolved greatly from the initial studies of Wendel. Anatomical closure of 90% or greater is not uncommon. However, one of the controversies that has plagued retina specialists over the past few years is how to achieve macular hole closure in larger macular holes. Large holes were defined by Gass as greater than 400 µm in size, and with the advent of OCT, specialists have migrated to measuring the diameter between the retinal tissues.
In this prospective clinical study, Manasa and colleagues randomized patients to receiving traditional macular hole surgery with ILM peels vs. ILM flap surgery for holes greater than 600 µm in size. Their results are one of the first studies to finally look at this on a head-to-head fashion and found significant benefit in ILM flap for these larger holes over traditional surgery and the ability to achieve the desired anatomic outcome by OCT.
The study is limited in that holes with a greatest linear diameter of 600 µm were entered. While it is arguably a large hole, there still lacks clinical classification at to what constitutes a large hole. Also, ILM flap as described here and in other studies is technically difficult to perform. Lastly, the authors followed these patients for only 3 months, and there is a chance that the traditional ILM removal patients within the trial would have improved over time.
In summary, this is a very important article demonstrating the early benefit of ILM flap surgery in patients with large macular holes.