Pars plana vitrectomy (PPV) combined with peeling of the internal limiting membrane (ILM) is used as a conventional procedure for treatment of a macular hole (MH). After Michalewska et al. in 2010 described the inverted ILM flap technique for large MH several modifications have been described, including the use of autologous lens capsular flap, and autologous neurosensory retinal flap or retinal transplant, some of them are difficult to perform by inexperienced vitreoretinal surgeons. Good and encouraging anatomical and functional outcomes with all the techniques described and the very promising visualization systems in 3D will reduce in the future some of the technical challenges, and help shorten the learning curve.

Material & Methods:

In this video, the authors present 2 clinical cases of 10 performed that show a modified easy technique for the closure of macular holes with a full-thickness defect > 400 μm: one case of idiopathic MH and another of secondary MH associated with macular edema in a patient with a branch retinal artery occlusion. Both of the vitreoretinal surgeries were performed with a 3D Visualization System. In the first step, free filtered triamcinolone acetonide was injected into the vitreous cavity to delineate the posterior hyaloid face and facilitate inducing posterior vitreous detachment (PVD). When the 23g vitrectomy was done, the internal limiting membrane was stained with membraneblue-dual® solution and an ILM circumference of approximately 2 disc-diameters around a circle whose centre was the MH was peeled off, the peripheral piece of ILM was trimmed, whereas the central part of ILM was left in place, superior half of the remaining ILM circle over the macula was peeling with an ILM forceps and left attached to the edge, this superior free semicircle ILM flap was fold down covering the fovea. We used the help of gravity to stabilize the inverted flap over the macula and a small amount of perfluorocarbon (PFC) keep it in position in the critical moment of fluid-air exchange followed by air-gas exchange with sulfur hexafluoride (SF6). In the 10 cases performed with this technique the anatomical closure rate was 100% and average best corrected visual acuity improved from logMAR (logarithm of the minimum angle of resolution) 0,7 to 0,3 at last follow-up.

Discussion & Conclusion:

We suggested that a single-layered ILM folding over the macula and flattening with PFC would be an easy technique that restored to normal fovea architecture, and would be more physiological, providing a more regular structure for glial proliferation and less inflammation that the multilayered ILM. The authors present a simple version of the inverted flap technique helped by the gravity force and the weight of PFC that can help to feel more comfortable in the closure of macular holes procedures. There are ten cases operated by this technique obtained anatomic and functional success.


University Hospital Infanta Leonor
Madrid, Spain
Email: marprieto20@yahoo.com
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