Internal Limiting Membrane (ILM) peeling is actually a common surgical procedure performed in different retinal disorders like epiretinal membrane, macular edema of various etiology, foveosquisis, macular hole or sub-ILM hemorrage. Current treatment of macular hole is vitrectomy associated to complete IML peeling or inverted IML flap technique. However, macular hole closure failure can occur in few cases after standard procedure. In the other hand, reopening of MH after successful surgery may happen. In particular cases with very high macular thickness, like foveoschisis or macular edema, a macular hole can develop after vitrectomy and complete ILM peeling. Refractory MH, reopened MH and secondary MH after previous complete ILM peeling are difficult cases to manage. Several procedures have been performed with unpredictable anatomical and functional results. In 2014, autologous transplantation of IML was described as a successful technique in previously ILM peeled MH cases. Autologous ILM transplantation is a difficult surgical procedure. The more extensive the previous ILM peeled area, the more difficult to peel an ILM fragment with adequate size. A bimanual technique is required to place the autologous ILM fragment in the floor of macular hole. In this video, the authors try to show some important tricks to place and keep autologous ILM fragment in position. Several cases of refractory macular holes and a secondary macular hole are presented. The secondary macular hole occurred after subretinal rTPA injection and IML peeling in a retinal macroaneurism with sub-ILM and subretinal hemorrages. Autologous ILM transplant has been performed in extremis cases with good anatomical results and satisfactory functional outcome. This is a technically difficult procedure that requires particular attention in several steps of the surgery.

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Natalia Ferreira