BACKGROUND: To compare the surgical outcomes of the inverted internal limiting membrane (ILM) flap technique and ILM insertion for macular hole (MH) without retinal detachment in eyes with extremely high myopia.
METHODS: In this retrospective study, we analyzed 22 eyes with an axial length ≥ 30.0 mm that had underwent MH surgery between April 2015 and August 2021. The surgical procedures involved either an inverted ILM flap or ILM insertion. The outcomes were compared between the two techniques. Closure of the MH was confirmed by optical coherence tomography (OCT). The best-corrected visual acuity (BCVA) was measured before and after surgery. Associated complications were documented.
RESULTS: The median of axial length was 30.64 mm (range, 30.0-34.42). The MH closed in 100% (22/22) eyes and did not recur with a median follow-up of 12.5 months. For the inverted ILM flap technique, the median BCVA improved significantly from 0.80 logarithm of the minimum angle of resolution (logMAR) (range, 0.40-2.00) before surgery to 0.70 logMAR (range, 0.09-1.52) after surgery (p = 0.002). In addition, the median of final BCVA was better for the inverted ILM flap than ILM insertion (0.7 logMAR V.S. 1.00 logMAR; p = 0.016).
CONCLUSIONS: In eyes with extremely high myopia, despite comparable effects on MH closure for both ILM insertion and the inverted ILM flap, the later technique achieved significantly better visual outcomes.

BACKGROUND: We compared postoperative metamorphopsia and optical coherence tomography (OCT) findings between eyes that underwent internal limiting membrane (ILM) peeling and the inverted flap (IF) technique for macular hole (MH).
METHODS: This retrospective analysis included 64 eyes of 64 patients with idiopathic MH whose MH was closed after initial surgery. Thirty-nine patients were treated with pars plana vitrectomy (PPV) with ILM peeling, and 25 patients were treated with PPV with the IF technique. Best corrected visual acuity (BCVA), severity of metamorphopsia, and OCT images were collected before and 3, 6, and 12 months postoperatively. Based on the OCT images, the status of the external limiting membrane (ELM) and ellipsoid zone and the presence of hyperreflective plugs were assessed.
RESULTS: At baseline and 3, 6, and 12 months postoperatively, BCVA and severity of metamorphopsia were not significantly different between groups. The status of the ELM was significantly worse in the IF group than in the ILM peeling group at 3 and 6 months postoperatively. Significantly more hyperreflective plugs were observed in the IF group than in the ILM peeling group at 3 and 6 months postoperatively. Stepwise multiregression analysis revealed that hyperreflective plugs were significantly associated with the severity of metamorphopsia at 12 months postoperatively.
CONCLUSIONS: The alterations on the OCT were fewer in the ILM peeling group than in the IF group, while no significant differences were observed in postoperative severity of metamorphopsia between groups. Metamorphopsia was worse in eyes with hyperreflective plugs.

Currently, vitrectomy is considered as the first line of treatment in the management of macular holes. Various surgical modalities have been described to obtain anatomical closure. However, there are still challenges when the hole is large and chronic (>400 microns) in nature. Here we describe a modified technique of internal limiting membrane (ILM) peeling which results in the successful closure of such macular holes.
To demonstrate modified ILM flap techniques in management of chronic macular holes.
Here we have described the role of modified ILM peeling techniques in three different cases such as chronic traumatic macular hole >400 microns, chronic idiopathic macular hole >400 microns and <400 microns.
This modified ILM flap technique provides the benefit of an inverted ILM flap, which helps in glial proliferation and also relives tangential traction thereby aiding in successful macular hole closure in chronic cases.
https://youtu.be/RKVLd1mSw08.

Globe perforation following peribulbar anesthetic injection is a rare but dreaded complication that often results in poor visual outcomes. This case report is on a female patient who sustained vitreous hemorrhage, retinal detachment, and macular breaks due to a peribulbar block administered in the setting of cataract extraction. The retina was repaired with pars plana vitrectomy, endolaser of the peripheral retinal break only, and an internal limiting membrane inverted flap for the macular breaks to avoid the endolaser on the macular area, achieving stable visual outcomes. The authors discussed various modes of local anesthesia for vitreoretinal surgery, risks for globe perforations, and how to approach retinal detachment secondary to needle perforations, which are complex cases at high risk for proliferative vitreoretinopathy. Early recognition and intervention in eyes with an inadvertent perforation can lead to a good outcome. Eyes with a longer axial length, superior, and multiple perforations are at higher risk of developing complications such as retinal detachment and vitreous hemorrhage. Complications such as retinal detachment, macular injury, and vascular occlusion are risk factors for poor prognosis.

Purpose: To report vitrectomy with the inverted internal limiting membrane (ILM) flap technique in a patient with a full-thickness macular hole (FTMH) and Coats disease. Methods: A case and its long-term findings were analyzed. Results: A 27-year-old patient with Coats disease who was treated 5 years earlier with laser photocoagulation presented with an FTMH. Vitrectomy with the temporal inverted ILM flap technique was performed. The macular hole decreased in size on serial OCT scans but did completely close until 18 months postoperatively. The final visual acuity was 20/40 (0.3 logMAR). The patient\'s vision remained stable for the next 5 years. Conclusions: Although the healing process after vitrectomy with ILM peeling and the inverted flap technique in an FTMH coexisting with Coats disease is prolonged compared with an idiopathic FTMH, it is still possible to obtain satisfactory anatomic and functional results.

OBJECTIVE: Inverted Inner Limiting Membrane (ILM)-flap approach can fail in the treatment of Optic disc pit maculopathy (ODPM). We report a surgical technique involving human amniotic membrane (hAM) patch implant to treat unresolved ODPM after inverted (ILM)-flap technique.
METHODS: One patient with decreased visual acuity (1 LogMar) after unsuccessful inverted ILM-flap technique to treat ODPM, underwent hAM patch implant and was evaluated. A surgical approach including a 2 mm size graft patch of hAM implantation over the optic disc pit followed by fluid-air exchange was performed. A gas endotamponade was finally used. The patient was instructed to maintain face-down position for the first three days after surgery. The hAM patch remained detectable over the pit for the entire 6-months follow-up. The ODPM gradually resolved and visual acuity partially recovered to 0.17 LogMar during follow-up. No postoperative complications or recurrence were reported.
CONCLUSIONS: hAM patch implant may be effective to manage ODPM after unsuccessful inverted ILM-flap.

OBJECTIVE: To demonstrate a modified technique of perfluorocarbon liquid (PFCL)/internal limiting membrane (ILM) interface staining in patients affected by macular hole retinal detachment (MHRD) in the setting of high myopia.
METHODS: Two-surgeon retrospective case series and review of surgical videos with step-by-step technique analysis.
RESULTS: Our modified technique was proficiently employed to treat 9 highly myopic patients affected by MHRD. Successful staining and peeling of the ILM with the creation of an inverted flap was achieved in all cases. A limited number of dye injections required to stain the ILM was noted. No subretinal dye migration or other intra- and postoperative complications were recorded.
CONCLUSIONS: Modified PFCL/ILM interface staining is a surgically efficient technique potentially reducing the risk of iatrogenic damage, including the toxicity of vital dyes to the retinal pigment epithelium (RPE) in myopic MHRD.

We present a case of a persistent macular hole which was initially treated by pars plana vitrectomy with the inverted ILM flap technique. In a second procedure, the internal limiting membrane (ILM) flap was mobilized from its perifoveal adherence to the retina and peeled back to its adherence at the foveal ring. The eye was filled with 25% C2F6 gas. Three weeks after the second procedure, closure of the hole was observed. Best corrected visual acuity increased from 20/400 to 20/50. We assume that contractile elements within the ILM may cause perifoveal adhesion and centrifugal effects preventing macular hole closure. If macular hole closure does not occur after surgery with an inverted ILM flap, it is worth to peel back the existing flap again towards the foveal edge in order to induce hole closure and preserve the benefits of flap surgery. If the flap is only attached to the foveal ring, centripetal contraction could lead to annular closure of the macular hole. If the flap is lost, alternative surgical methods for refractory MHs should be considered.

Pars plana vitrectomy has become the standard procedure for primary macular holes (MHs) repair, including the removal of the posterior cortical vitreous, the stripping of eventual epiretinal membranes, and finally an intraocular gas tamponade. During this procedure, peeling the internal limiting membrane (ILM) has been proven to increase closure rates and avoid postoperative reopening in several researches. In fact, even in large MHs more than 400 µm, the advantage of peeling off the ILM was highlighted by better anatomical closure rates. Nevertheless, some authors suggested that ILM peeling is not always essential, because it generates various side effects in retinal structure and function. Furthermore, the ideal amount of ILM peeling and the most effective strategies for removing the ILM are still subject of research. Different surgical modifications have been reported as alternatives to traditional peeling in certain clinical settings, including ILM flaps, ILM scraping, and foveal sparing ILM peeling. As regards large MHs, the introduction of ILM inverted flap appeared as a game changer, offering a significantly higher >90% closure rate when compared to traditional ILM peeling. Modifications to inverted ILM flap procedures have been claimed in recent years, in order to define the best area and direction of ILM peeling and its correlation with functional outcomes. Moreover, several innovations saw the light in the setting of recurrent MHs, such as ILM free flap transposition, inverted ILM flap combined autologous blood clot technique, neurosensory retinal flap, and human amniotic membrane (HAM) plug, claiming higher anatomical success rate also in those complex settings. In conclusion, the aim of this review is to report how the success rate of contemporary macular surgery has grown since the turn of the century, especially for big and chronic MHs, analyzing in which way ILM management became a crucial point of this kind of surgery.

We demonstrate a modified internal limiting membrane (ILM) inverted flap technique for closure of macular holes (MHs) concurrent with rhegmatogenous retinal detachment in myopic eyes. Multiple ILM flaps were created in a flower-petal configuration around the MH over the detached retina after shallowing the retina as much as possible. Traction was always in a direction that allowed the optic disc to act as an anchor to limit iatrogenic breaks and to bridge the hole with multiple, more secure flaps should one of the flaps revert or break away. The technique proved safe and efficient in MH closure in our series of eight cases. The modification described provides an effective approach for challenging myopic cases in which ILM flap creation is needed over a detached retina.