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Narayanan, Raja MD, MBA*; Singh, Sumit R. MD*; Taylor, Stanford MD; Berrocal, Maria H. MD; Chhablani, Jay MD*; Tyagi, Mudit MD*; Ohno-Matsui, Kyoko MD, PhD§; Pappuru, Rajeev R. MD*; Apte, Rajendra S. MD, PhD

doi: 10.1097/IAE.0000000000002186
Original Study

Purpose: To evaluate the anatomical and visual outcomes of inverted flap technique of peeling of internal limiting membrane (ILM) versus standard peeling of ILM for macular holes of basal diameter more than 800 μm.

Methods: Patients with very large idiopathic macular holes more than 800 μm in basal diameter (ranging from 243 μm to 840 μm in minimum diameter) were retrospectively included in the study. In Group A, 18 eyes of 18 patients underwent ILM peeling using the inverted flap technique. In Group B, 18 eyes of 18 patients underwent conventional ILM peeling. The primary endpoint was the rate of hole closure at 6 months after surgery. The secondary outcome measure was the change in best-corrected visual acuity at 6 months after surgery.

Results: There were no significant differences in ocular characteristics of the study groups at baseline except for the age distribution. Mean macular hole diameter was 1,162.8 ± 206.0 μm and 1,229.6 ± 228.1 μm in Group A and Group B, respectively. The hole closure rate was 88.9% (16/18) in Group A and 77.8% (14/18) in Group B (P = 0.66). The mean gain in best-corrected visual acuity was higher in Group A than in Group B (P = 0.12) at 6 months, but this was not statistically significant. There were no severe ocular adverse events in either group.

Conclusion: In this multicenter series, inverted ILM flap technique did not lead to significantly higher anatomical closure rates than conventional ILM peeling in large macular holes more than 800 μm in diameter.

The inverted internal limiting membrane flap is a recent surgical technique that provides marginally better functional and anatomical results in very large macular holes compared with the conventional technique.

*Smt. Kanuri Santhamma Centre for Vitreo-Retinal Diseases, L V Prasad Eye Institute, Hyderabad, India;

Department of Ophthalmology and Visual Sciences, Washington University School of Medicine, St Louis, Missouri;

University of Puerto Rico School of Medicine, San Juan, Puerto Rico; and

§Tokyo Medical and Dental University, Tokyo, Japan.

Reprint requests: Rajendra S. Apte, MD, PhD, Department of Ophthalmology and Visual Sciences, Washington University School of Medicine, St Louis, Missouri 63110; email:

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

© 2019 by Ophthalmic Communications Society, Inc.