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Chatziralli, Irini, P., MD, PhD*; Theodossiadis, Panagiotis, G., MD, PhD*; Steel, David H., W., MBBS†,‡

doi: 10.1097/IAE.0000000000001959

Purpose: To review the current rationale for internal limiting membrane (ILM) peeling in macular hole (MH) surgery and to discuss the evidence base behind why, when, and how surgeons peel the ILM.

Methods: Review of the current literature.

Results: Pars plana vitrectomy is an effective treatment for idiopathic MH, and peeling of the ILM has been shown to improve closure rates and to prevent postoperative reopening. However, some authors argue against ILM peeling because it results in a number of changes in retinal structure and function and may not be necessary in all cases. Furthermore, the extent of ILM peeling optimally performed and the most favorable techniques to remove the ILM are uncertain. Several technique variations including ILM flaps, ILM scraping, and foveal sparing ILM peeling have been described as alternatives to conventional peeling in specific clinical scenarios.

Conclusion: Internal limiting membrane peeling improves MH closure rates but can have several consequences on retinal structure and function. Adjuvants to aid peeling, instrumentation, technique, and experience may all alter the outcome. Hole size and other variables are important in assessing the requirement for peeling and potentially its extent. A variety of evolving alternatives to conventional peeling may improve outcomes and need further study.

This review discusses the rationale for internal limiting membrane peeling in macular hole surgery and outlines current theories about why, how, and when the internal limiting membrane should be peeled, including a number of recently described variants to the basic technique.

*Second Department of Ophthalmology, National and Kapodistrian University of Athens, Athens, Greece;

Sunderland Eye Infirmary, Sunderland, United Kingdom; and

Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom.

Reprint requests: David H. W. Steel, MBBS, Sunderland Eye Infirmary, Queen Alexandra Road, Sunderland, SR2 GHP, United Kingdom; e-mail:

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

© 2018 by Ophthalmic Communications Society, Inc.