Perfluorocarbon Liquid-Assisted Inverted Limiting Membrane Flap Technique Combined With Subretinal Fluid Drainage for Macular Hole Retinal Detachment in Highly Myopic Eyes : RETINA

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Perfluorocarbon Liquid-Assisted Inverted Limiting Membrane Flap Technique Combined With Subretinal Fluid Drainage for Macular Hole Retinal Detachment in Highly Myopic Eyes

Hu, Zizhong MD, PhD; Gu, Xunyi MD; Qian, Huiming MD; Liang, Kang MD; Zhang, Weiwei MD; Ji, Jiangdong MD; Chen, Qin MD; Liu, Qinghuai MD, PhD; Xie, Ping MD, PhD

Editor(s): Williams, George A.

Author Information
doi: 10.1097/IAE.0000000000002600

Macular hole retinal detachment (MHRD) mostly develops in highly myopic eyes. Owing to tangential macular traction by the vitreoretinal interface, presence of a posterior staphyloma, or an atrophy of the retinal pigment epithelium (RPE),1 MHRD in myopic eye is a challenging disease for vitreoretinal surgeons. Pars plana vitrectomy with several procedures, including internal limiting membrane (ILM) removal, intraocular gas or silicone oil tamponade, and scleral imbrication, has been attempted to improve the anatomical retinal reattachment. However, a successful MH closure in myopic eyes with MHRD is still difficult to achieve. Recently, an inverted ILM flap technique devised by Michalewska et al2 has been reported for treating myopic macular hole with retinal detachment, which increase the MH closure rate.3–5 In these reports, complete drainage of subretinal fluid (SRF) could not be performed through MH in that peeling ILM flap prone to detach from retina during this procedure. In some cases that the extensive retinal detachment extended to or beyond the equator, drainage of SRF was performed through the retinal hole intentionally created outside the macular hole.5,6 Here, we report a perfluoro-n-octane–assisted inverted ILM flap technique for MHRD in highly myopic eyes, which enables complete drainage of SRF during surgery.

Surgical Technique

This study is conducted following the principles of the Declaration of Helsinki. Informed consent was also obtained from each patient involved. The step-by-step technique of perfluorocarbon liquid (PFCL)–assisted inverted ILM flap for MHRD is described in Figure 1 and video (see Video, Supplemental Digital Content 1, Phacoemulsification is performed with intraocular lens implant if the patient has significant lens opacity. A standard pars plana vitrectomy is performed using the Constellation sutureless 23-gauge or 25-gauge vitrectomy system (Alcon Laboratories, Inc, Fort Worth, TX) under a noncontact viewing system Resight 700 (Carl Zeiss Meditec AG, Jena, Germany). The main surgical procedure is as followed:

  1. Unless it has already spontaneously occurred, a posterior vitreous detachment is induced, and the posterior hyaloid is completely removed using triamcinolone-assisted visualization.
  2. A small bubble of PFCL (DK-line; Bausch & Lomb) is introduced to cover the exposed RPE under the MH.
  3. Indocyanine green (ICG, 1.25 mg/mL; Eisai, Inc, Shenyang, China) dye is then injected over the macular area to stain the ILM and after this with an immediate lavage.
  4. Any epiretinal membrane is peeled off whenever present. The ILM is peeled to the superior and inferior arcade margin. The nasal, superior, and inferior ILM is peeled off circumnavigating the MH, whereas the remaining one-quarter ILM on the temporal part is half peeled.
  5. Air–fluid exchange is then performed to drainage the SRF through the macular hole with a flute needle as completely as possible to reattach the retina.
  6. Subsequently, PFCL is gently introduced over the macula and ensure the remaining ILM is under the PFCL, following by fluid–air exchange to ensure the vitreous is filled with PFCL and balanced saline solution above.
  7. The ILM forceps is then used to regrasp the advancing edge of the remaining ILM and invert the ILM to cover the MH.
  8. Finally, the balanced saline solution is removed as completely as possible before removing the PFCL. Perfluorocarbon liquid is drained on the nasal retina to macular hole with the patient's head rotating to the nasal.
  9. Silicon oil is induced initially on the macular hole to avoid displacement of the above inverted ILM. Patient is then suggested to maintain a facedown position for 1 week.

Fig. 1.:
Schematic drawing of step-by-step flow chart of PFCL-assisted ILM flap technique for MHRD. A. Half-peel one-quarter ILM in the temporal part. B. Peel-off the nasal, superior, and inferior ILM. C. Drainage the SRF to reattach the retina. D. Introduce the PFCL to cover the macula. E. Regrasp the advancing edge of the remaining ILM, and invert the ILM to cover the macular hole. F. Remove the remnant fluid and PFCL. Green: ILM. Yellow: Retina. Pink: SRF. Blue: PFCL.


To date, we have performed the technique on 13 highly myopic eyes with MHRD in 13 consecutive patients. Table 1 shows the preoperative baseline characteristics of all cases. The patient population was consisted of 9 women (69.23%) and 4 men with a mean age of 61.61 ± 9.69 years. In four eyes, retinal detachment was within arcade, and in nine eyes, retinal detachment was beyond arcade. The average axial length was 30.18 ± 0.95 mm.

Table 1. - Demographic Data of Patients
Number Age/Sex/Eye Axial Length Extent RD* Macular Hole Sealed Retinal Reattachment Follow-up (mo) Remnant SRF BCVA, Snellen Va Ratio (logMAR)
Initial Final
1 74/F/OD 29.56 2 Yes Yes 6 No CF (2.3) 20/100 (0.70)
2 55/M/OS 30.23 1 Yes Yes 4 No HM (2.6) 20/66 (0.52)
3 54/F/OS 30.60 2 Yes Yes 4 No HM (2.6) 20/66 (0.52)
4 53/F/OD 31.10 2 Yes Yes 3 No HM (2.6) 20/66 (0.52)
5 73/M/OS 28.56 2 Yes Yes 3 No CF (2.3) 20/200 (1.0)
6 56/F/OD 29.03 1 Yes Yes 3 No CF (2.3) CF (2.3)
7 60/M/OS 30.47 1 Yes Yes 2 No CF (2.3) 20/490 (1.39)
8 80/F/OS 30.23 2 Yes Yes 1 No HM (2.6) 20/662 (1.52)
9 48/F/OD 29.50 2 Yes Yes 1 Yes HM (2.6) 20/400 (1.30)
10 59/M/OS 30.12 2 Yes Yes 0.5 No CF (2.3) 20/200 (1.0)
11 68/F/OS 30.85 2 Yes Yes 0.25 No HM (2.6) 20/200 (1.0)
12 66/F/OS 29.86 1 Yes Yes 0.25 No HM (2.6) HM (2.6)
13 55/F/OS 32.28 2 Yes Yes 0.25 No HM (2.6) 20/28 (0.15)
*The extent of RD: within arcade is one; beyond arcade is 2.
BCVA, best-corrected visual acuity; CF, counting fingers; F, female; HM, hand movements; LogMAR, logarithm of minimal angle of resolution; M, male; OD, right eye; OS, left eye; RD, retinal detachment.

No intraoperative or postoperative complications related to the PFCL-assisted inverted ILM flap technique for MHRD were noted. All cases achieved initial retinal reattachment and macular hole closure on SD–optical coherence tomographic in few days after surgery. After an average follow-up of 2.17 months, all patients maintained macular hole closure and retina reattachment. Of note, in Case 9, macular hole was sealed and the retina was reattached after 7 days, but SRF accumulated at the 1-month follow-up (Figure 2).

Fig. 2.:
Optical coherence tomographic findings after PFCL-assisted ILM flap technique for patients with MHRD.

With respect to the functional outcomes, the best-corrected visual acuity was improved in 11 eyes (84.6%) and stable in two eyes at the final follow-up examination. The mean preoperative logMAR best-corrected visual acuity was 2.39 ± 0.19 (ranging from HM [2.6] to FC [2.3]), which improved to 1.12 ± 0.71 (ranging from HM [2.6] to 20/28 [0.15]) (P < 0.01) postoperatively (Table 1).


Retinal detachment from MH usually occurs in highly myopic eyes because of the stronger traction, as compared with nonmyopic eyes. The surgical treatment of MHRD aims to seal the macular hole and obtain retinal reattachment. However, the closure rate of MH in MHRD eyes is also poor, compared with idiopathic macular holes. The inverted ILM flap technique, first described by Michalewska et al,2 for large macular hole, was recently introduced to treat myopic macular hole4,5 with a higher MH closure rate. However, the retinal reattachment cannot be obtained during surgery with the standard ILM flap technique. In this report, we used the inverted ILM flap technique but modified the technique with two steps: first, we drained the SRF directly through the macular hole to reach an instant retinal reattachment; second, the ILM flap was created after SRF drainage and covered the MH with the assistance of PFCL. Our results showed that our technique facilitates the SRF drainage while stabilize the ILM flap in position, which in turn promotes the hole closure and retinal reattachment.

It still remains a controversial issue whither or not to intentionally absorb SRF completely enough during surgery for highly myopic eyes with MHRD, especially when the retinal detachment is localized within the arcade. Kelly and Wendel,7 and Charles8 suggested the MH surgery procedure may cause secondary trauma to the RPE and photoreceptors during MH surgery. Okuda et al9 further reported macular holes could be closed over residual SRF for MHRD eyes. However, in some cases, as observed by Okuda et al and us, the SRF of MHRD is commonly very viscous and may stay persistent over months if not absorbed during surgery. As reported by Shao et al10 and Tabandeh et al,6 SRF indicated a worse prognosis for surgical intervention of high myopia macular holes. In a recent study that did not use SRF drainage, Nadal et al11 reported relatively lower reattachment rates and MH closure in 51.9% of cases. Besides, the impairment of RPE pump function in degenerative myopia would further delay absorption or allow for further accumulation of SRF, weakening the adhesive properties surrounding the MH, aggravating damage to photoreceptors, and decreasing anatomical success and decreasing postoperative anatomical restoration and functional recovery. Of note, the hypothesis of secondary damage to RPE or photoreceptors during MH surgery was raised in premicroincision and pre–optical coherence tomographic area. The 23- or 25-gauge incisions, high-resolution microscope, and high-speed vitreous cute rate allow us much more safely to perform pars plana vitrectomy and macular manipulation. Thus, SRF drainage has been supported and performed through macular hole or iatrogenic extramacular hole.12 In this report, we found no remarkable damage to RPE or photoreceptors in optical coherence tomographic images for all patients in follow-ups.

Nevertheless, once the standard ILM flap technique is performed, the SRF under the ILM flap could not be drained during surgery. On the other hand, if the SRF was first drained during gas–fluid exchange, the ILM flap would be difficult to visualize and create because of the gas that filled the vitreous cavity. Our technique aimed to solve the two issues. We recommended ILM peeling and ILM flap creation should be conducted before SRF drainage. The ILM peeling procedure could be easily performed before gas–fluid exchange. Perfluorocarbon liquid is also of great significance in this technique. A bubble of PFCL on MH before indocyanine green staining is protectable for macular. After gas–fluid exchange, the PFCL is useful in the procedure of inverting and stabilizing the ILM flap.

Our study has several limitations. First, sample size was relatively small, and a larger number of cases are needed. Second, all the surgeries were performed by one experienced surgeon, which ignored the learning effects during procedures. Third, the expanding gas is not currently available in China; therefore, silicon oil was filled in each case. Further study is needed to investigate the efficiency of air or long-acting gas in this technique. A future study is also required to compare results with or without the drainage of SRF.


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macular hole retinal detachment; internal limiting membrane; perfluorocarbon liquid; subretinal fluid; highly myopia

Supplemental Digital Content

Copyright © 2019 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Opthalmic Communications Society, Inc.