To report a case in which an internal limiting membrane (ILM) flap that was used to cover an idiopathic macular hole (MH) during pars plana vitrectomy (PPV) with the inverted internal limiting membrane flap technique partially detached from the retina. Most interestingly, the flap fell back spontaneously to re-cover the MH.
A 70-year-old woman presented with a full-thickness MH, and her vision was 20/400. She underwent PPV with an inverted ILM flap and air tamponade. When the intraocular gas was absorbed, the ILM flap detached but was held to the retina where it had not been peeled and the MH was open. Her visual acuity at this time was 20/400. The patient did not want further treatment and was followed by observation alone. At three months after the initial surgery, the ILM flap was noted to have spontaneously re-covered the MH, and her visual acuity improved to 20/200. At 6 months after the re-covering, the flap remained over the MH and the visual acuity remained at 20/200.
Conclusions and Importance
Surgeons should be aware that it is possible for an ILM flap created by the inverted ILM flap technique to partially detach from the retina after the tamponade gas is resorbed. Most importantly, the flap can return to re-cover the MH spontaneously.
The recent advances of surgery for idiopathic macular holes (MHs) including the inverted internal limiting membrane (ILM) flap technique have increased the rate of primary closures. The inverted ILM flap technique has been shown to be especially helpful in closing large and chronic MHs. It was suggested that the successful closure of a MH by the inverted ILM flap method was because the flap provided scaffolding for the proliferating and migrating glial cells. However, the exact mechanism has still not been definitively determined.
We present a case in which the flap created during the inverted ILM flap technique partially detached from the retina, and the MH re-opened. Most interestingly, with observation alone, the ILM flap fell back to re-cover the MH.
A 70-year-old woman reported metamorphopsia and blurred vision in her left eye of six months duration. A full-thickness MH was detected by her previous doctor, and she was referred to Chiba University hospital for treatment. At our initial examination, her vision was 20/400 in the left eye with a refractive error of −2.0 diopters and intraocular pressure of 16 mmHg in the right eye and 17 mmHg in the left eye. She had mild cataract and a stage 3 MH in her left eye. The diameter of the MH was 630 μm which is a relatively large size ( Fig. 1 ).
She underwent pars plana vitrectomy (PPV) combined with phacoemulsification and implantation of an intraocular lens with a 25-gauge system by one of the authors (TB). Brilliant blue G (ILM blue, DORC, Netherland) was used to make the ILM more visible, and the superior half of the ILM adjacent to the MH was peeled off the retina. The flap was hinged at the superior border of the macular hole. Then the ILM was folded over but not pushed into the MH, and fluid-gas exchange was performed to tamponade the flap against the retina. The patient was instructed to maintain face-down positioning for three days.
The coverage of the MH by the ILM flap was confirmed on postoperative day 3 by optical coherence tomography (OCT; Fig. 2 a). However, the MH was noted in the OCT images to be open at two weeks after the surgery. The ILM flap was not covering the MH but remained attached where it had not been peeled ( Fig. 2 b). Her BCVA was 20/400 at this time. We suggested a reoperation but the patient declined.