平坦部玻璃体切除术已成为原发性黄斑裂孔(MHs)修复的标准程序,包括切除后皮质玻璃体,最终视网膜前膜的剥离,最后是眼内气填塞。在此过程中,在多项研究中,剥离内界膜(ILM)已被证明可以提高闭合率并避免术后重新开放。事实上,即使在超过400µm的大型MHs中,更好的解剖闭合率突出了剥离ILM的优势.然而,一些作者认为,ILM剥离并不总是必不可少的,因为它对视网膜结构和功能产生各种副作用。此外,理想的ILM剥离量和最有效的去除ILM的策略仍然是研究的主题。据报道,在某些临床环境中,不同的手术修饰可替代传统的剥离术。包括ILM襟翼,ILM刮削,和中央凹保留ILM剥离。至于大型MHs,ILM倒置皮瓣的引入似乎是一个改变游戏规则的人,与传统的ILM剥离相比,提供显著更高的>90%的闭合率。近年来,人们声称对倒置ILM皮瓣程序进行了修改,为了定义ILM剥离的最佳区域和方向及其与功能结果的相关性。此外,几项创新在经常性MHs的设置中看到了光明,如ILM游离皮瓣转位,倒置ILM皮瓣联合自体血凝块技术,视网膜神经感觉瓣,和人羊膜(HAM)塞,在那些复杂的环境中也声称更高的解剖学成功率。总之,这篇综述的目的是报告自世纪之交以来,当代黄斑手术的成功率是如何增长的,特别是对于大型和慢性MHs,分析ILM管理成为这种手术的关键点。
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.