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Large full-thickness macular holes can be difficult to close successfully with conventional internal limiting membrane (ILM) peeling alone. Randomized evidence has evaluated inverted ILM flap techniques, in which a remnant of peeled ILM is positioned over the hole to provide a scaffold for tissue remodeling. One randomized-control trial compared conventional ILM peeling with an inverted flap in large idiopathic macular holes and reported numerically higher anatomic closure with the flap technique. Other randomized work has shown that once an inverted flap is created, extensive manipulation of the flap may not be necessary to achieve high closure rates. For vitreoretinal surgeons, these data support the concept of matching the surgical technique to hole size and chronicity rather than treating all macular holes identically. The procedure also introduces technical considerations including preservation of the flap, avoidance of excessive retinal trauma, and management of the postoperative gas and positioning protocol. While the evidence is not uniformly definitive for every macular-hole phenotype, inverted ILM strategies have become an important option for large or difficult holes, especially when conventional peeling is considered less likely to provide reliable closure.
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Large full-thickness macular holes can be difficult to close successfully with conventional internal limiting membrane (ILM) peeling alone. Randomized evidence has evaluated inverted ILM flap techniques, in which a remnant of peeled ILM is positioned over the hole to provide a scaffold for tissue remodeling. One randomized-control trial compared conventional ILM peeling with an inverted flap in large idiopathic macular holes and reported numerically higher anatomic closure with the flap technique. Other randomized work has shown that once an inverted flap is created, extensive manipulation of the flap may not be necessary to achieve high closure rates. For vitreoretinal surgeons, these data support the concept of matching the surgical technique to hole size and chronicity rather than treating all macular holes identically. The procedure also introduces technical considerations including preservation of the flap, avoidance of excessive retinal trauma, and management of the postoperative gas and positioning protocol. While the evidence is not uniformly definitive for every macular-hole phenotype, inverted ILM strategies have become an important option for large or difficult holes, especially when conventional peeling is considered less likely to provide reliable closure.
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