Outer Retina Reconstruction Following Inverted Internal Limiting Membrane Flap for Large Stage 4 Macular Holes



Inverted internal limiting membrane (ILM) flaps have shown good anatomical closure rates and often improved visual outcome when used for the treatment of large macular holes, whose results have been erstwhile unsatisfactory with conventional ILM peel techniques. How ever, in several cases of successful closure of the macular hole the outer retina may not be present as is seen in successfully closed smaller size macular holes. Presence of outer retina is an impor tant expected outcome of successful intervention following macular hole repair. Post operative absence of outer retina implies that this category of macular holes though closed anatomically, may still require some other yet to be determined intervention that offers superior outcome in reconstructing the outer retina layers.


To evaluate the degree of outer retina reconstruction using SD OCT in a series of large stage 4 macular holes.


A retrospective review of 14 consecutive eyes of 14 patients who had an inverted internal limiting membrane (ILM) flap technique for the repair of large macular hole from April 2015 to Jan 2017 was done. The pre and postoperative SD OCT images looking for the presence of the ELM and IS/OS junction in the subfoveal and parafoveal area was done. The ELM and IS/OS was categorized into present or absence. When present it was further categorized into present continuous (if there was no interruption between the subfoveal and parafoveal extent of the IS/OS and ELM) or present discontinuous or broken ( if there was an interruption between the subfoveal and parafoveal components of either the IS/OS and the ELM).


The average macular whole base diameter for all cases was 963microns. There was absence of outer retina in 6 eyes, average base diameter for these eyes is 1242 microns; continuous presence of outer retina in the sub and parafoveal area in 4 eyes , average hole diameter in this group of eyes was 652 microns and lastly there was a broken or discontinuous presence of outer retina in 4 eyes, average hole diameter is 855 microns.


The outer retina in large macular holes treated with ILM flap technique can undergo reconstitution. There is growing need for further categorization of large macular holes into those with outer retina reconstruction following inverted ILM flap and those without. We found that the average macular hole size for eyes with complete reconstitution was 652 microns and 855 for those without complete reconstitution. It may be safe to expect outer retina reconstitution after inverted ILM flap with macular holes within this range. The eyes without any outer retina reconstruction however had an average of 1242 microns, suggesting that eyes within this limit may be candidates for other forms of intervention in which outer retina reconstitution may be achieved. The small sample size and retrospective nature is an obvious limitation of this study. Multicenter studies will provide better information on this topic.


Ogugua Okonkwo
Lagos, Nigeria
Email : oguguaokonkwo@ymail.com
Cell Phone: +2348035027308
Work Phone: +2348035027308