We read with great interest the article by Chen and Yang, entitled “Inverted internal limiting membrane insertion for macular hole–associated retinal detachment for high myopia.” The authors describe a new technique for treating macular hole–associated retinal detachment in high myopic patients. The idea seems interesting; however, there are some points that need further clarification.

Firstly, the authors do not mention the size of the macular hole, which is very important for the outcome of the procedure. Moreover, it is possible that the pre-existing small macular hole could be irregularly enlarged after the insertion of the internal limiting membrane (ILM) material.

Secondly, in the article by Chen and Yang it is not mentioned if the group of patients who underwent vitrectomy, inverted ILM insertion into the macular hole, and air-fluid exchange includes cases with foveoschisis. If it does happen, what is the outcome of the procedure regarding the success rate?

The absorption of subretinal fluid in the proposed technique is a matter that needs further consideration for 2 different reasons: the inserted ILM tissue into the hole creates a column, which keeps a distance between retinal pigment epithelium and retinal layers, as is shown in Figure 3. Moreover, in a great proportion of highly myopic eyes, the Bruch membrane is absent. This absence is associated with complete loss of retinal pigment epithelium, choriocapillaries, and photoreceptor layers. In retinal reattachment after surgery, subretinal fluid is mainly absorbed by the retinal pigment epithelium pump and therefore its absence renders difficult or impossible the subretinal fluid absorption. On the other hand, according to the authors, “the macular buckling approach is a successful technique, since it changes the macular contour, decreases the axial length, and decreases the vitreoretinal traction and the traction induced by posterior eyeball elongation.” In fact, the macular buckling technique causes permanent contact between the sclera and the macular area, leading to absorption of subretinal fluid. The authors’ concern related to the possible defects of the chronic compression by the buckle does not seem to affect the short posterior ciliary arteries, as it has been shown at the 15-year follow-up of the scleral buckling technique.

Another finding that should be clarified is the observed significant improvement of visual acuity after the procedure. The different homogeneity between the inserted-into-the-hole ILM flap and the surrounding neural structure does not help in transmitting the nervous stimulus, and therefore the improvement of visual acuity remains questionable.