The article titled “Inverted Internal Limiting Membrane Insertion for Macular Hole–Associated Retinal Detachment in High Myopia” addresses a well-thought-of surgical procedure. However, its utility as an alternative to existing procedures in restoring vision is doubtful for the following reasons.

In assessing the results of the surgery, the authors assess Snellen visual acuity as a measure of success. For a validated assessment, follow-up assessment needs to include microperimetry and visual field analysis. Microperimetry may be helpful in predicting the outcome of macular hole surgery. In a study by Amari and associates, visual outcome correlated with the maximum sensitivity adjacent to the hole. Macular holes result in dense scotomata with steep margins. After repair of macular holes and using vitrectomy, a high incidence of inferotemporal and temporal peripheral field loss has been reported after uncomplicated surgery. Damage to the peripapillary nerve fiber layer as attached vitreous is stripped off the nasal portion of the disc has been implicated as the cause. Earlier reports have favored direct compression of the peripheral nasal retina by a gas bubble as the likely cause.

When a macular hole forms and there is release of tangential traction from surgery or spontaneous vitreous separation, the plasticity of the retina reduces the size of the hole and the hole is healed by proliferation of fibrous astrocytes and Müller cells. Hence, as the authors described, the procedure closes the hole already filled with glial tissue.

Furthermore, if the tangential traction is incompletely relieved, then further traction may occur with some of the reparative tissue and, rarely, retinal tissue remaining attached to the vitreous. More extensive glial cell proliferation may occur after surgery and possibly contribute to recurrence of the macular holes. Only a long-term follow-up would confirm whether the claimed improvement in vision is a chance occurrence or is attributable to the repair, as the surgery itself promotes further glial proliferation in the macular hole to the existing proliferated tissue.

The authors used different machines to measure the peripapillary retinal nerve fiber layer (RNFL). It has been reported that measurements differ between machines. Measurements with these instruments should not be considered interchangeable, as absolute measurements of peripapillary RNFL thickness differed between Stratus and Spectralis machines. Savini and associates measured RNFL thicknesses and compared between 2 Fourier-domain machines. One machine yielded higher mean RNFL thickness values in all quadrants; another machine generates higher peripapillary RNFL thickness readings. This should be kept in mind when values obtained with different instruments are compared during follow-up.