Inverted Pedicled Internal Limiting Membrane Flap Attached to an Optic Disc with Autologous Blood Clot for Large Macular Holes

Abstract

Purpose. An inverted ILM flap might be accidentally separated from the retina or sucked away during surgery for large macular holes (MHs). This article is to determine the efficacy of a new inverted pedicled internal limiting membrane (ILM) flap attached to an optic disc with an autologous blood clot (ABC) technique for the treatment of large MHs. Methods. An inverted pedicled ILM flap connected to the optic disc with ABC was used to treat 12 consecutive patients with significant macular holes (>600 m). The ILM was first peeled off around MH as a semidiameter of about 1.5 diameters of the optic disc. The superior residual ILM was used to produce a pedicled ILM flap that was connected to the optic disc and was later inverted to cover the MH. The macular hole was covered with a repositioned flap larger than 2 MH diameters in an inverted way. ABC was used to fasten the flap, followed by fluid-air exchange with air or C3F8 as tamponade. Spectral domain-optical coherence tomography (SD-OCT) and best-corrected visual acuity (BCVA) were performed at each postoperative follow-up. Results. The mean aperture and base macular hole diameters were 737.9 ± 109.6 µm (range, 607–982 µm) and 1244.3 ± 227.4 µm (range, 975–1658 µm). All macular holes (100%) were closed after a single surgery without intraoperative or postoperative complications related to the ILM transposition technique. At the last postoperative visit, we found one eye with a U-shaped closure, three eyes with W-shaped closures, and eight eyes with V-shaped closures. No postoperative flap closures were noted in all cases. The preoperative mean BCVA was 1.5 ± 0.3 (range, 1.1–2.0). After a mean follow-up of 5.3 ± 4.8 (range, 3–16) months, the postoperative mean BCVA was 0.8 ± 0.2 (range, 0.6–1.1), and the difference was statistically significant ( $p<0.05$ ). Conclusion. This novel technique is safe and suitable for large MHs and can be an alternative option for accidental ILM flap loss during other inverted ILM flap operations.