In highly myopic eyes, macular hole is one of the most vision-threatening complications due to visual impairment and the risk of developing a retinal detachment. Possible pathogenetic factors in are tangential traction attributable to the vitreous or hyaloid membrane and vertical traction attributable to the elongation of posterior staphyloma. However, these factors are not clearly elucidated in highly myopic macular holes. Many techniques have been developed in an attempt to improve macular hole closure rates, such as epiretinal membrane (ERM) and internal limiting membrane (ILM) peeling, endolaser photocoagulation of the macular hole, arcuate partial retinotomy and silicone oil tamponade. ILM peelling has good results for nonmyopic macular holes, but its success decreases in myopic eyes and retinoschisis. Michalewska described the efficacy of inverted ILM flap technique for idiopathic large macular hole and some reports have shown the efficacy of this technique in myopic macular holes. This prevents reopening macular hole and improves functional and anatomic outcomes. We present a case of a myopic macular hole treated with inverted ILM flap technique.

Case Report:

A 55-year old woman presented with decrease of visual acuity for one month. She has -15 diopters. She presented a preoperative BCVA of 0.05 (Snellen). Funduscopic examination revealed posterior staphyloma, and OCT revealed a macular hole with a minimal diamenter of 900mm and macular retinoschisis. We performed 23 g 3-port pars plana vitrectomy, and a posterior vitreous detachment was created. ILM was first stained with brilliant blue and peeled off in a circular fashion for approximately 2 disc diameters around the macular hole. Most of the ILM detached was removed, except a triangle in the superior area, which was maintained attached to the edge of the macular hole and rolled over the hole until covered. Fluid-air exchange was performed and then 22% SF6 gas implanted, keeping the ILM over the hole. One month after the procedure the hole was closed and the BCVA was improved to 0.15.


Myopic macular holes have very poor anatomic and functional prognosis treated with ILM peeling. This is even worse if retinoschisis is present. Inverted ILM flap stimulates proliferation of glial cells that can fill macular holes, improving the macular hole closure rate and postoperative visual acuity. Although ILM peeling is the initial treatment suggested for several authors even in myopic eyes, we performed the inverted ILM flap procedure because this technique allows complete removal of cortical vitreous, complete relaxation of the tangential forces of the retina and also provides proliferating cells which fill the hole. This technique provides for successful anatomic and visual recovery and could be used as initial treatment of large myopic macular holes associated with retinoschisis.

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