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Casini, Giamberto MD*; Mura, Marco MD; Figus, Michele MD, PhD*; Loiudice, Pasquale MD*; Peiretti, Enrico MD; De Cillà, Stefano MD§; Fuentes, Taiusha MD*; Nasini, Francesco MD*

doi: 10.1097/IAE.0000000000001470
Original Study

Purpose: To determine whether surgical manipulation steps of the internal limiting membrane (ILM) flap, such as ILM trimmed, ILM tuck inside the hole, ILM massage, are mandatory to obtain satisfactory outcomes for the repair of large stage IV idiopathic macular hole using the inverted ILM flap technique.

Methods: In this interventional comparative prospective single-masked study, 81 eyes were randomized into 2 treatments groups. In Group 1 (41 eyes), the classic inverted ILM flap technique was performed. In Group 2 (40 eyes), a modified procedure was used: after ILM peeling, no extra flap manipulation was performed. The macular hole was covered by the inverted ILM flap because of the air pressure at the time of the fluid–air exchange.

Results: At 12 months, macular hole closure was observed in 40 eyes (97.6%) in Group 1 and in 39 eyes in Group 2 (97.5%). U-shape closure rate, ellipsoid zone defects, and external limiting membrane defects were similar in both groups. The results indicate no statistical difference in anatomical and functional success between both groups.

Conclusion: The macular hole closure rate, improved visual acuity, and no extra complications indicate noninferiority of the modified inverted ILM technique. Internal limiting membrane finishing, tucking, and massage may not be required to obtain surgical success.

Supplemental Digital Content is Available in the Text.The inverted internal limiting membrane flap technique for macular hole surgery is a well-know procedure that requires surgical manipulation of the inverted flap. A modified and simplified version of this technique (without extra manipulation of the flap) seems to provide comparable results.

*Department of Surgical, Medical, Molecular and Critical Area Pathology, University of Pisa, Pisa, Italy;

The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland. The King Khaled Eye Specialist Hospital, Retina Division, Riyadh, Kingdom of Saudi Arabia;

Eye Clinic, University of Cagliari, Cagliari, Italy; and

§Department of Health Sciences, Eye Clinic, University of Piemonte Orientale, Novara, Italy.

Reprint requests: Francesco Nasini, MD, U.O. Oculistica Universitaria, University of Pisa, Via Paradisa 2, Pisa 56124, Italy; e-mail:

None of the authors has any financial/conflicting interests to disclose.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

© 2017 by Ophthalmic Communications Society, Inc.