Inverted ILM flap technique improves outcomes of macular hole surgery


By Cheryl Guttman Krader; Reviewed by Jerzy Nawrocki, MD, PhD

The inverted internal limiting membrane (ILM) flap technique can be successfully used for the repair of a wide spectrum of macular holes, said Jerzy Nawrocki, MD, PhD.

Dr. Nawrocki

The technique, developed by Dr. Nawrocki and his colleague Zofia Michalewska, MD, PhD, involves covering the macular hole with an inverted remnant of ILM that is left attached to the margins of the macular hole after ILM peeling.

The inverted ILM technique was first used for large macular holes (> 400 µm), and results of a prospective, randomized clinical trial [Ophthalmology. 2010;117(10):2018-2025] showed that compared with standard surgical repair, the inverted ILM flap technique achieved its goal of preventing the postoperative flat-open appearance of large macular holes and was associated with better visual acuity.

Subsequently, Drs. Nawrocki and Michalewska have applied the technique and a modification–the temporal inverted ILM flap technique–with success in a range of macular holes.

“The inverted ILM flap technique achieves regeneration of the structure of the fovea and photoreceptor layer in the fovea, and that correlates with improvement in visual acuity,” said Dr. Nawrocki, Ophthalmic Clinic Jasne Blonia, Lodz, Poland.

“When we first reported on our use of the inverted ILM flap technique, we already suggested it might be used in all cases of macular holes,” Dr. Nawrocki. “Our experience and reports from other surgeons confirm its efficacy. I encourage retina specialists who have not used this technique to give it a try.”

Expanding indications

After reporting on the utility of the inverted ILM flap technique for large macular holes, Drs. Nawrocki and Michalewska applied it successfully in eyes with myopic macular holes without retinal detachment [Retina. 2014;34(4):664-669]. In a series of 19 eyes with myopia > 6 D or axial length > 26.5 mm that were followed prospectively for at least 12 months, they found improvement in mean visual acuity and a 100% closure rate.

“With spectral-domain optical coherence tomography imaging, we documented decreased photoreceptor and external limiting membrane defects that correlated with the improvement in visual acuity,” Dr. Nawrocki said.

Success using the inverted ILM flap technique for repair of myopic macular holes was subsequently reported by other investigators.

“One finding from this experience showed the inverted ILM flap technique achieved ‘mission impossible’ with closure of macular holes in eyes with axial length of 30 mm or more which were not possible to close with ILM peeling and gas,” said Dr. Nawrocki.


Temporal inverted technique

In 2015, Drs. Nawrocki and Michalewska reported on the temporal inverted ILM flap technique as a variation of their original approach [Retina. 2015;35(9):1844-1850]. In the modification, the ILM is peeled only on the temporal side of the fovea, but left attached at the margin of the macular hole. The macular hole is covered with this temporal ILM flap.

Results from a randomized study showed that the modified and original inverted ILM flap techniques were associated with the same visual acuity and anatomical closure rates. The temporal method, however, caused less surgical trauma, as documented by the less frequent appearance of nerve fiber layer defects in the area between the optic nerve and fovea.

The temporal inverted and the inverted ILM flap technique also have been used successfully for the surgical repair of macular holes associated with rhegmatogenous retinal detachment, soft drusen, subretinal fibrosis post-trauma, and proliferative diabetic retinopathy. Dr. Nawrocki noted that in eyes with retinal detachment, subretinal fluid is drained through the hole, without touching the hole, prior to covering the hole with the ILM flap.

Fluid persistence may be observed for weeks or months after surgery, even if the macular hole is closed, and eventually reabsorbs. Similarly, it can take several months for subretinal fluid to reabsorb after surgery in eyes with proliferative diabetic retinopathy.




Because of the high anatomic success rate of the inverted ILM flap technique, reoperations in cases managed with this approach have been rare. Outcomes using the inverted ILM flap technique are favorable and better than with hole-edge massage, but not as good as in primary cases, Dr. Nawrocki said.

Reviewing outcomes in a series of eyes operated on from 2001 to 2014 for failure of macular closure, Dr. Nawrocki reported that the closure rate was 45% using hole-edge massage in 11 eyes versus 90% in 32 eyes operated on with the inverted ILM flap technique. Repeat surgery brought the closure rate up to 80% for hole-edge massage and to 100% for the inverted ILM cohort. Final logMAR VA in the 2 surgical groups was 0.77 and 0.56, respectively.

“We see during reoperation for cases of failure after inverted ILM flap technique surgery that the flap has moved away from the macular hole,” Dr. Nawrocki said. “After putting the flap back onto the surface of the retina, we see that it stays stable and there is a chance for anatomic and functional recovery.”

Jerzy Nawrocki, MD, PhD


This article is based on a presentation given by Dr. Nawrocki at the 2017 Retina World Congress.  He has no relevant financial interests to disclose.


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