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INVERTED INTERNAL LIMITING
MEMBRANE FLAP TECHNIQUE FOR
TREATMENT OF MACULAR HOLE
RETINAL DETACHMENT IN HIGHLY
MYOPIC EYES
HIROYUKI TAKAHASHI, MD, MAKOTO INOUE, MD, TAKASHI KOTO, MD, YUJI ITOH, MD,
KAZUNARI HIROTA, MD, AKITO HIRAKATA, MD
Purpose: To compare the efficacy of vitrectomy with inverted internal limiting membrane
(ILM) flap to complete removal of the ILM for the treatment of macular hole (MH) retinal
detachment in highly myopic eyes.
Methods: Pars plana vitrectomy with inverted ILM flap technique (16 eyes; inverted
group) or with the complete removal of the ILM (16 eyes; removed group) was performed in
patients with high myopia with MH retinal detachment. The rate of retinal reattachment and
MH closure, the best-corrected visual acuities, and the integrity of the foveal
microstructures in the optical coherence tomographic images were compared.
Results: Thirteen eyes (81%) in the inverted group and 15 eyes (93%) in the removed
group had retinal reattachment after the initial surgery (P = 0.30). The MH was
closed significantly more often in the inverted group (75%) than in the removed group
(25%; P = 0.006). The postoperative best-corrected visual acuity was significantly better
in the inverted group (P = 0.04). The number of eyes with outer nuclear layer, external
limiting membrane, and ellipsoid zone lines at the closed MH was not significantly different
in the two groups.
Conclusion: The inverted ILM flap technique with the presence of bridging tissue over
the MH is effective in closing the MH and improving the postoperative best-corrected visual
acuity in eyes with MH retinal detachment by bridging tissue over the MH.
RETINA 0:1–10, 2017
M
due to tangential macular traction by the vitreoretinal
interface, presence of a posterior staphyloma, or an
atrophy of the retinal pigment epithelium.3–5 Pars plana vitrectomy with additional procedures, including
epiretinal membrane removal, internal limiting membrane (ILM) removal, intraocular gas or silicone oil
tamponade, and scleral imbrication, has been successful in releasing the tension, resulting in the reattachment of the retina.6–10 However, a successful MH
closure and recovery of the visual acuity in eyes with
MHRD are still difficult to achieve, and some patients
require multiple procedures for anatomical success.
An inverted ILM flap technique was recently
reported to be effective in closing idiopathic MHs.11
In this technique, the ILM is not completely removed
from the retina around the MH but is inverted to form
a cover over the MH. In previous case series, this
acular hole retinal detachment (MHRD) can
develop in highly myopic eyes, and these eyes
require immediate surgical intervention because
MHRD can lead to irreversible retinal damage.1,2 In
highly myopic eyes, MHRD has been reported to be
From the Kyorin Eye Center, Department of Ophthalmology,
Kyorin University School of Medicine, Tokyo, Japan.
None of the authors has any financial/conflicting interests to
disclose.
Involved in management, analysis, interpretation, and preparation of the data (H.T., M.I., T.K., Y.I., K.H., and A.H.).
Involved in interpretation and preparation of the manuscript
(H.T., M.I., and A.H.).
The corresponding author (M.I.) had full access to all the data in
the study and takes responsibility for the integrity of the data and
the accuracy of the data analysis.
Reprint requests: Makoto Inoue, MD, Kyorin Eye Center,
Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka,
Tokyo 181-8611, Japan; e-mail: inoue@eye-center.org
1
Copyright ª by Ophthalmic Communications Society, Inc. Unauthorized reproduction of this article is prohibited.
2
RETINA, THE JOURNAL OF RETINAL AND VITREOUS DISEASES 2017 VOLUME 0 NUMBER 0
technique achieved MH closure more successfully not
only for idiopathic MHs but also for MHs and
MHRDs in highly myopic eyes.12–16 Several surgeons
have used this technique with some modifications such
as the insertion of the peeled ILM into the MH or
sealing the ILM flap with a venous blood clot.17,18
Although these newer procedures seem to be promising for the management of MHRD, the effectiveness
of this inverted ILM flap technique has still not been
definitively determined and further case–control studies are needed.
Thus, the purpose of this study was to evaluate the
effectiveness of the inverted ILM flap technique in
reattaching the retina and closing the MH in eyes with
MHRD. To accomplish this, we compared the MH
closure rates and retinal reattachments after the
inverted ILM technique with that after a complete
removal of the ILM. We shall show that the inverted
ILM flap technique had better anatomical and visual
success than conventional ILM removal for eyes
with MHRD.
Methods
The medical records of 58 eyes of 58 consecutive
patients with MHRD were reviewed. All the patients
were referred to the Kyorin Eye Center from April
2012 to February 2016. Only eyes with an axial length
$26.5 mm were studied, and eyes with previous vitreoretinal surgery, trauma, diabetic retinopathy, retinal
vein occlusion, uveitis, and other retinal diseases were
excluded. All the patients underwent preoperative and
postoperative standard ophthalmologic examinations
that included stereoscopic observations of the fundus
and measurements of the best-corrected visual acuity
(BCVA). The preoperative age, sex, axial length, lens
status, estimated duration of the decreased vision, and
rate of combined cataract surgery were collected. The
BCVA was determined using a Landolt C chart, and
the decimal BCVAs were converted to the logarithm
of the minimum angle of resolution units for statistical
analyses. The axial length was measured using
OA1000 (Tomey, Nagoya, Japan). The area of the
RD was determined for each patient by the images
from a panoramic scanning laser ophthalmoscope (Optos 200Tx; Optos PLC, Dunfermline, Scotland). The
findings were used to classify patients into those
whose RD was within the vascular arcade or whose
RD extended beyond the vascular arcade. The presence of chorioretinal atrophy due to myopic chorioretinal degeneration at the fovea was determined by
fundus autofluorescence at 6 months after the surgery.
The eyes with MHRD were divided into two
groups; eyes that underwent pars plana vitrectomy
with the inverted ILM flap technique (inverted group)
and eyes that underwent pars plana vitrectomy with
complete ILM removal (removed group). The preoperative and postoperative BCVA at 12 months after
surgery and the rates of reattachment and MH closure
after the first surgery were compared in the 2 groups.
For patients who had pars plana vitrectomy
with silicone oil endotamponade during the initial
surgery, the retinal reattachment was confirmed after
successful removal of the silicone oil within 12
months. The significance of the differences in the
different parameters between the two groups was
determined statistically.
All the patients received a detailed explanation of
the surgical and ophthalmic examination procedures,
and all signed an informed consent form. The
procedures adhered to the tenets of the Declaration
of Helsinki, and they were approved by the Institutional Review Committee of the Kyorin University
School of Medicine. All the patients consented to our
review of their medical records. This clinical study has
been registered at the U.S. National Institutes of
Health (www.clinicaltirals.gov) as “Inverted internal
limiting membrane flap technique for macular hole
retinal detachment in highly myopic eyes,” with a reference number of NCT02896972.
Evaluation by Optical Coherence Tomography
The macular area was scanned with a swept-source
(SS) optical coherence tomography (OCT) instrument
(SS-OCT; DRI OCT-1; Topcon, Tokyo, Japan) 96
times with a 12-mm length with the eye at the primary
position. Spectral domain OCT (SD-OCT, Spectralis;
Heidelberg Engineering, Heidelberg, Germany) was
also used for eyes without intravitreal gas. The
presence of an MH was confirmed in the SD-OCT
or swept-source OCT images preoperatively or confirmed with the surgical microscope intraoperatively
by the surgeons (M.I., T.K., K.H., and A.H.).
The rate of MH closure, presence of the outer
nuclear layer (ONL), external limiting membrane
(ELM) line, and ellipsoid zone (EZ) were evaluated
in the SD-OCT or SS-OCT images (Figure 1). The
presence of a uniform hyperreflective bridging tissue
that plugged the MH without any retinal layer was also
determined. The evaluations of MH closure and foveal
microstructures were made by two observers (T.K. and
Y.I.), who were masked to the patients’ information.
When the decision was not the same, a third
investigator (M.I.) examined and discussed the
findings to make the final decision.
Copyright ª by Ophthalmic Communications Society, Inc. Unauthorized reproduction of this article is prohibited.
MYOPIC MACULAR HOLE RETINAL DETACHMENT TAKAHASHI ET AL
3
Surgical Procedures
All the surgeries were performed by experienced
vitreous surgeons (M.I., T.K., K.H., and A.H.) under
local or general anesthesia. The vitrectomies were
performed with 23-, 25-, or 27-gauge instruments
depending on surgeons’ preference. Cataract surgery
was performed when needed, and the central vitreous
core was removed. Adhesion of the posterior hyaloid
membrane to the macula was confirmed by the surgeon. Intravitreal triamcinolone acetonide (MaQaid;
Wakamoto Pharmaceutical Co, Ltd, Tokyo, Japan)
was used to make the vitreous gel more visible. After
triamcinolone acetonide was injected and removed, the
posterior hyaloid or epiretinal membrane was carefully
peeled with forceps or removed by suction with a vitreous cutter. The ILM was stained with brilliant blue G
for 30 seconds, and either peeled over the entire macular area in the removed group or placed over the MH
as an ILM flap in the inverted group. The selection of
which procedure to use was made by the surgeon. The
subretinal fluid was drained through the MH or
through an intentional retinal hole, or not drained.
The air was then replaced with nonexpanding perfluoropropane or sulfur hexafluoride, or silicone oil, and the
patient was instructed to maintain a facedown position.
Silicone oil was used for patients whose fellow eye
had severe visual disturbances or elderly patients who
were not able to maintain a facedown position. Scleral
imbrication was performed by placing mattress sutures
at the temporal quadrant as an optional procedure.
Statistical Analysis
The significance of the differences in the baseline
characteristics, surgical procedures, and surgical outcomes between the two groups was evaluated
by Mann–Whitney U tests or Fisher’s exact possibility tests. A P value of ,0.05 was taken to be
statistically significant.
Results
Fig. 1. Grading of the closed MH after vitrectomy for MHRD. A. The
ELM and EZ (arrowheads) can be clearly seen at the closed MH. The
ONL is well preserved at the closed MH. B. The ELM (arrowheads) and
the EZ are disrupted at the closed MH, but the ONL is continuous at the
closed MH. C. The ELM, the EZ, and the ONL (arrowheads) are disrupted at the closed MH. The closed MH is covered with the tissue
connected to the inner nuclear layer. D. The ELM, the EZ, and the ONL
are disrupted at the closed MH. A uniform hyperreflective bridging
tissue (arrowhead) without any retinal layer plugs the defect of the
sensory retina at the closed MH.
There were 3 men and 29 women who met the
inclusion criteria. The mean (±SD) age of the patients
was 68.7 ± 8.2 years with a range of 50 years to 90
years. None of the patients dropped out during the
follow-up period. There were 21 phakic eyes, 10 pseudophakic eyes, and 1 aphakic eye preoperatively, and
the mean preoperative axial length was 29.3 ± 1.5 mm
with a range of 26.8 mm to 32.9 mm. Sixteen eyes
underwent the inverted ILM flap technique (inverted
group) and 16 eyes had the ILM completely removed
(removed group). Preoperatively, there was no
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4
RETINA, THE JOURNAL OF RETINAL AND VITREOUS DISEASES 2017 VOLUME 0 NUMBER 0
Table 1. Baseline Characteristics of Patients With MHRD Who Underwent Inverted ILM Flap Technique or Complete ILM
Removal
Inverted ILM Flap Technique
(16 Eyes)
Complete ILM Removal
(16 Eyes)
P
68.4 ± 7.8
2/14
29.1 ± 1.9
10/6/0
69.1 ± 8.5
1/15
29.6 ± 1.1
11/4/1
0.84*
0.50†
0.27*
0.48†
25 ± 15
45 ± 26
0.03*
8 (50%)
9 (56%)
0.72†
20/138
0.84 ± 0.48
20/270
1.13 ± 0.53
0.11*
Age (year, mean ± SD)
Sex (male/female)
Axial length (mm, mean ± SD)
Lens status (phakia/pseudophakia/
aphakia)
Duration of decreased vision (day,
mean ± SD)
Extent of RD beyond the vascular
arcade
Mean preoperative BCVA
Preoperative BCVA
(logMAR unit, mean ± SD)
*Mann–Whitney U test.
†Fisher’s exact probability test.
logMAR, logarithm of the minimum angle of resolution.
significant difference in age, sex distribution, lens status, axial length, extent of RD, and decimal BCVA
between the two groups (Table 1). Patients in the inverted group had a shorter duration of decreased vision
than those in the removed group.
There was no significant difference in the number of
eyes that had aspiration of subretinal fluid, use of gas
or silicone tamponade, or duration of facedown
position between the two groups (Table 2). More patients in the inverted group underwent vitrectomy with
smaller gauge instruments than in the removed group.
Among the 16 eyes of the removed group, 8 eyes
received scleral imbrication of the temporal quadrant
as an additional procedure. None of the eyes had macular buckling as the initial surgery.
Comparisons of the postoperative outcomes
between the two groups are presented in Table 3. After
the initial surgery, the retina was reattached in 13 eyes
in the inverted group (81%) and 15 eyes in the
removed group (94%; P = 0.30; Figures 2 and 3). Of
the remaining four eyes, two eyes required additional
surgeries for recurrences of the RD. All the eyes
achieved retinal reattachment, but 2 eyes required silicone oil tamponade for more than 12 months after the
initial surgery.
Fundus autofluorescence showed chorioretinal
atrophy at the fovea in two eyes in the inverted
group (13%) and 1 eye in the removed group (6%;
P = 0.54). The MH was closed in 12 eyes (75%) in
the inverted group, which was significantly higher
than the 4 eyes (25%) in the removed group at 3, 6,
and 12 months (P , 0.01 for all, Fisher’s exact
probability test). Spectral domain OCT showed that
the microstructure of the tissue closing the MH
Table 2. Surgical Procedure of Patients With MHRD Who Underwent Inverted ILM Flap Technique or Complete ILM
Removal
Gauge of vitrectomy instruments
(23G/25G/27G)
Combined cataract surgery
Presence of attached posterior
hyaloid or epiretinal membrane
Scleral imbrication of temporal
sclera (%)
Aspiration of subretinal fluid (%)
Tamponade (SF6/C3F8/SO)
Mean period of a facedown position
(day), mean (range)
Inverted ILM Flap Technique
(16 Eyes)
Complete ILM Removal
(16 Eyes)
P
0/15/1
6/10/0
0.02†
12 (75%)
15 (94%)
9 (56%)
15 (94%)
0.23†
1.0
0 (0)
8 (50)
0.002†
13 (81)
4/10/2
12 (2–37)
14 (88)
6/5/5
12 (2–40)
0.50†
0.19†
0.97*
*Mann–Whitney U test.
†Fisher’s exact probability test.
C3F8, perfluoropropane; SF6, sulfur hexafluoride; SO, silicon oil.
Copyright ª by Ophthalmic Communications Society, Inc. Unauthorized reproduction of this article is prohibited.
5
MYOPIC MACULAR HOLE RETINAL DETACHMENT TAKAHASHI ET AL
Table 3. Retinal Reattachment and MH Closure in Patients With MHRD
No. of eyes
Initial retinal reattachment (%)
Final reattachment including eyes
filled with silicon oil (%)
Foveal chorioretinal atrophy (%)
MH closure (%)
1 week
1 month
3 months
6 months
12 months
Recovery of retinal microstructure of
the closed MH at postoperative 6
months (%)
ONL (+) ELM (+) EZ (+)
ONL (+) ELM (+) EZ (2)
ONL (+) ELM (2) EZ (2)
ONL (2) ELM (2) EZ (2) HBT (2)
ONL (2) ELM (2) EZ (2) HBT (+)
Mean BCVA at 12 months
BCVA at 12 months (logMAR unit,
mean ± SD)
Mean BCVA at 12 months in eyes
without foveal chorioretinal
atrophy
BCVA at 12 months in eyes without
foveal chorioretinal atrophy
(logMAR unit, mean ± SD)
Inverted ILM
Flap Technique
Complete ILM
Removal
P
16
13 (81)
16 (100)
16
15 (94)
16 (100)
0.30*
.0.99*
2 (13)
1 (6)
10
11
12
12
12
(63)
(69)
(75)
(75)
(75)
4
4
4
4
4
(25)
(25)
(25)
(25)
(25)
3 (25)
0 (0)
3 (25)
4 (33)
2 (17)
20/96
0.68 ± 0.42
1 (25)
0 (0)
1 (25)
2 (50)
0 (0)
20/182
0.96 ± 0.35
20/85
20/163
0.63 ± 0.40
0.91 ± 0.37
0.54*
0.07*
0.02*
,0.01*
,0.01*
,0.01*
0.76*
.0.99*
0.76*
0.49*
0.55*
0.04†
0.03†
*Fisher’s exact probability test.
†Mann–Whitney U test.
HBT, hyperreflective bridging tissue; logMAR, logarithm of the minimum angle of resolution.
differed among the eyes. In some of the tissues, the
ELM, EZ, and uniform hyperreflective bridging tissue with and without photoreceptor outer segments
were present (Figure 3).
The differences in the number of eyes with tissue
containing the ONL, ELM, and EZ at the closed MH
at postoperative 6 months, or with the ONL but
without the ELM and EZ were not significant between
the groups (Table 3). In addition, the differences in the
number of eyes without the ONL, ELM, EZ, and the
hyperreflective bridging tissue were also not significant between the groups (Table 3). The number of
eyes without the ONL, ELM, and EZ but with the
hyperreflective bridging tissue was not significantly
different between the two groups (Table 3). Eyes with
an ONL and ELM but without the EZ were not present
in both groups. The decimal BCVA was significantly
better in eyes in the inverted group than in the
removed group (P = 0.04, Mann–Whitney U test).
The anatomical and visual outcomes of eyes with
a restoration of ONL at the closed MH were compared
with eyes without the ONL for the inverted and
removed groups (Table 4). The number of eyes with
a restoration of the ONL was not significantly different
between the inverted group and the removed group.
The recovery of the ELM and EZ lines were significantly more frequent in eyes with a presence of the
ONL, but the eyes with a hyperreflective bridging tissue were not significantly different. The eyes with
a restoration of the ONL had significantly better
BCVA than eyes without a restoration of the ONL
at postoperative 12 months (P = 0.04, Mann–
Whitney U test).
The surgical outcome of scleral imbrication was
compared with eyes without scleral imbrication in the
removed group (Table 5). The results showed that the
age, sex distribution, axial length, lens status, duration
of decreased vision, and extent of the RD were not
significantly different between the two groups. The
mean preoperative and postoperative BCVA in
logarithm of the minimum angle of resolution units
were significantly better in eyes with scleral
imbrication (P = 0.01). However, the postoperative
mean BCVA was not significantly different from the
Copyright ª by Ophthalmic Communications Society, Inc. Unauthorized reproduction of this article is prohibited.
6
RETINA, THE JOURNAL OF RETINAL AND VITREOUS DISEASES 2017 VOLUME 0 NUMBER 0
Fig. 2. Wide-field fundus images and swept-source OCT
images of a 61-year-old woman
with MHRD in the inverted
group. A. Preoperative wide-field
fundus image showing inferior
bullous RD (arrowheads) extending beyond the vascular
arcade in the left eye. B. Postoperative wide-field fundus
image at 6 months showing a reattached retina and chorioretinal
atrophic lesion surrounding
Fuchs spots (white arrowhead)
with peripheral patchy lesion
(black arrowhead). C. Preoperative OCT image in a vertical scan showing detached retina
and MH with an epiretinal
membrane (arrowhead). D. Postoperative OCT image in a horizontal scan at Day 4 shows
retinal reattachment through the
intravitreal gas with its hyperreflective surface (arrowheads).
Hyperreflective tissue (white
arrow) within the closed MH and
choroidal
neovascularization
(yellow arrow) can be seen
beside the closed MH. E. Postoperative OCT image at 1 month
shows hyperreflective tissue
(white arrowhead) located next
to
the
choroidal
neovascularization (yellow arrow)
which is covered with thin neural
retina. The edge of the EZ (yellow arrowhead) is seen around
the closed MH. F. Postoperative
OCT image at 6 months shows
closed MH covered with multilayered neural retinal tissue
(white arrow) beside the choroidal neovascularization (yellow arrow). The edge of the EZ (yellow arrowhead) is present next to the closed MH.
preoperative mean BCVA in eyes with scleral imbrication (0.76, 0.79, respectively, P = 0.79) and without
scleral imbrication (1.14, 1.48, respectively, P = 0.09).
Discussion
The results showed that a retinal attachment and
MH closure was attained in highly myopic eyes with
MHRD after pars plana vitrectomy with either the
inverted ILM flap technique or after the complete
removal of the ILM. In previous studies, the initial
retinal reattachment rate varied from 40% to 93.5%
after pars plana vitrectomy with or without ILM
removal.19 Our results are comparable with these results, and only 2 of the 32 patients with MHRD had
a recurrence of the RD.
Lim et al20 investigated the surgical outcome of 114
MHRD eyes, and 95 of these eyes (83.3%) had the
ILM removed. They reported that a retinal attachment
and MH closure were achieved in 55 eyes (48%) by
the initial surgery. In earlier studies, the MH closure
rate after vitrectomy with ILM peeling for MHRD
ranged from 10% to 91%.7,8,21–24 Our results showed
that eyes with MHRD that underwent pars plana vitrectomy with the inverted ILM flap technique had significantly higher rates of MH closure (75%) than those
that had pars plana vitrectomy with complete ILM
removal (25%). The rate of MH closure after vitrectomy with the inverted ILM flap technique or with the
insertion of the ILM into the MH of 80% to 100% has
been reported to be higher than that after vitrectomy
with ILM peeling of 33% to 56%.14–16
Our results showed that the eyes with MHRD had
better BCVA after vitrectomy with the inverted ILM
flap technique than with complete ILM removal.
Matsumura et al16 reported significant visual improvements after the use of the inverted ILM flap technique
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MYOPIC MACULAR HOLE RETINAL DETACHMENT TAKAHASHI ET AL
7
Fig. 3. Wide-field fundus images and OCT images of a 67year-old woman with MHRD in
the inverted group. A. Preoperative wide-field fundus
image shows RD (arrowheads)
extending beyond the vascular
arcade in the left eye. B. Postoperative wide-field fundus
image at 6 months shows reattached retina and posterior
staphyloma
(arrowheads)
including optic disk and macula
with several patchy chorioretinal
atrophic areas. C. Preoperative
swept-source OCT image in
a vertical scan shows MH and
detached retina. D. Postoperative
swept-source OCT image in
a vertical scan on Day 2 shows
retinal reattachment, but MH is
not closed (arrow) under intravitreal gas (white arrowheads).
Focal choroidal excavation
(black arrowhead) appears as
a hyporeflective cavity between
the outer retina and sclera at the
superior edge of the fovea. E.
Postoperative swept-source OCT
image at 1 month shows
incomplete closure of the MH
that is covered by the inverted
ILM (white arrowheads). Hyperreflective tissue (arrow) at the
inner edge of the MH can be
seen. The retina is invaginated at
the focal choroidal excavation
(black arrowhead). F. Postoperative spectral domain OCT
image at 6 months shows closed
MH covered with hyperreflective bridging tissue (black
arrowhead) and migrated retinal
tissue with multiple retinal layers (black arrow).
but not after ILM removal. Sasaki et al15 reported that
the postoperative BCVA at 6 months was significantly
better in the inverted ILM flap technique than the eyes
after ILM peeling. Baba et al14 found no significant
difference in median visual acuity after vitrectomy
with the ILM flap technique and ILM peeling at 12
months, although significantly higher MH closure was
obtained after the inverted ILM technique. The prognosis of MHRD after inverted ILM flap technique is
still controversial, although successful MH closure
after ILM peeling was reported to contribute to better
visual outcome in patients with MHRD.20
Highly myopic eyes are frequently associated with
patchy atrophy and chorioretinal atrophy, and macular
autofluorescence with foveal involvement has been
described as a poor prognostic factor after vitrectomy
for MHRD.25 Our results showed that the incidence of
foveal chorioretinal atrophy detected by foveal fundus
autofluorescence was not significantly different
between the two groups. This may be the reason
why our results showed significant visual improvements after the inverted ILM flap technique compared
with ILM peeling.
Hayashi and Kuriyama26 reported a restoration of
the EZ and ELM lines at the closed MH after vitrectomy with inverted ILM flap technique in 6 of 35
(17%) highly myopic eyes with MHRD. They concluded that the foveal photoreceptor layer was destroyed and did not recover even after MH closure
and retinal reattachment. In our study, the SD-OCT
and SS-OCT images of the eyes with the inverted
ILM flap surgery suggested that the base of the
closed MH was made up of tissues that had migrated
into the MH with detection of the ONL at the closed
MH in 50% of the inverted group. Okuda et al27
reported that an MH closure was seen initially over
the subretinal fluid before the retinal reattachment by
the inverted ILM flap technique for MHRD.
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8
RETINA, THE JOURNAL OF RETINAL AND VITREOUS DISEASES 2017 VOLUME 0 NUMBER 0
Table 4. Comparison of Anatomical and Visual Outcome Between Eyes With and Without Restoration of the ONL After
Successful Retinal Reattachment and MH Closure
Restoration of ONL
No. of eyes
Surgical procedure
Inverted ILM flap technique
Complete ILM removal
Recovery of ELM and EZ (%)
Hyperreflective bridging tissue (%)
Mean BCVA at 12 months
BCVA at 12 months (logMAR unit,
mean ± SD)
Yes
No
8
8
6
2
4 (50)
0 (0)
20/78
0.59 ± 0.48
6
2
0 (0)
2 (25)
20/145
0.86 ± 0.26
P
.0.99*
.0.99*
0.04*
0.23*
0.04†
*Fisher’s exact probability test.
†Mann–Whitney U test.
logMAR, logarithm of the minimum angle of resolution.
Müller cells. Replacement of the nonneural tissue at
the fovea which was seen as hyperreflective bridging
tissue without the ONL at the closed MH by OCT in
17% of the inverted group. This prohibited the
recovery of the foveal microstructures and may
cause central visual disturbances, scotomas, or
distorted vision.25 Even in the eyes without any
restoration of the ONL at the closed MH, the
hyperreflective bridging tissue at the closed MH
may play a role in preventing recurrences of the
RD. Because of the small number of cases, the
A restoration of the ONL with recovery of the ELM
and the EZ lines over the closed MH was associated
with better BCVAs in 50% of the eyes. Accordingly,
it can be hypothesized that the ILM tissue may help in
the translocation of photoreceptor cells toward the
closed MH, leading to the visual improvement. By
contrast, a lack of restoration of the ONL but with
the hyperreflective bridging tissue at the closed MH
indicated that the MH was closed with scarred tissue
or migrated glial tissue including collagen
components derived from the inverted ILM or the
Table 5. Comparison of Preoperative and Postoperative Demographics of Patients With MHRD Who Underwent Pars
Plana Vitrectomy With or Without Scleral Imbrication and Complete ILM Removal
Scleral Imbrication
No. of eyes
Age (years, mean ± SD)
Sex (male/female)
Axial length (mm, mean ± SD)
Lens status (phakia/pseudophakia/
aphakia)
Duration of decreased vision (days,
mean ± SD)
Extent of RD beyond vascular
arcade (%)
Mean preoperative BCVA
Preoperative BCVA (logMAR unit,
mean ± SD)
Initial retinal reattachment (%)
Final retinal reattachment (%)
MH closure (%)
Mean postoperative BCVA at 12
months
Postoperative BCVA at 12 months
(logMAR unit, mean ± SD)
P
Yes
No
8
67.9 ± 7.6
0/8
29.5 ± 1.1
6/2/0
8
70.3 ± 9.1
1/7
29.6 ± 1.1
5/2/1
43 ± 17
46 ± 32
3 (38)
6 (75)
0.16†
20/123
0.79 ± 0.33
20/604
1.48 ± 0.47
0.01*
7 (88)
8 (100)
3 (38)
20/115
8 (100)
8 (100)
1 (13)
20/278
0.76 ± 0.19
1.14 ± 0.35
0.71*
0.30†
0.92*
0.58†
.0.99*
0.50†
.0.99†
0.28†
0.01*
*Mann–Whitney U test.
†Fisher’s exact probability test.
logMAR, logarithm of the minimum angle of resolution.
Copyright ª by Ophthalmic Communications Society, Inc. Unauthorized reproduction of this article is prohibited.
MYOPIC MACULAR HOLE RETINAL DETACHMENT TAKAHASHI ET AL
current study could not determine the factors
determining the visual outcome after the inverted
ILM flap technique for patients with MHRD. In
addition, the incidence of combined cataract surgery
was higher and the duration of decreased vision was
shorter in the inverted group.
In the removed group, scleral imbrication was
performed in eight eyes. Ando et al28 reported that
scleral imbrication reduced the degree of curvature
of the posterior staphyloma detected with 3D magnetic resonance imaging. However, the initial retinal
reattachment and the macular closure rate were not
significantly different between vitrectomy with and
without the scleral imbrication. This is why no eyes
were treated by vitrectomy with the inverted ILM
technique initially in combination with scleral
imbrication.
Our study has several limitations. First, the number
of cases was relatively small, and a larger number of
cases are needed. Second, 12 months might be too
short a follow-up period because it is not uncommon
that recurrences of RD can develop after a long
postoperative period. Third, we evaluated only the
BCVA, and other visual functions such as the visual
fields (scotoma), and metamorphopsia should be
evaluated.
In conclusion, the inverted ILM flap technique is
effective in achieving retinal reattachments and MH
closure leading to postoperative visual improvements
for highly myopic eyes with MHRD. The OCT results
after surgery suggests that the inverted ILM tissue may
play a role in forming a base for the tissue closing the
MH and to induce the recovery of the foveal
microstructures.
Key words: high myopia, macular hole retinal
detachment, optical coherence tomography, pars plana
vitrectomy, internal limiting membrane.
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17.
18.
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Copyright ª by Ophthalmic Communications Society, Inc. Unauthorized reproduction of this article is prohibited.
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