case_images: PMC10798096_01
case_images: Schematic diagram of temporal inverted limiting membrane (ILM) flap technique. (a) After creating a semicircular ILM notch (blue arrow) from the temporal edge of the macular hole (MH) (red circle), the indocyanine green-stained ILM flap that formed on the temporal side of the macula was flipped toward the nasal side (blue dotted arrow) to cover the MH completely. (b) Cross-sectional view of the temporal inverted ILM flap technique (intraoperative optical coherence tomography). The figure shows the temporal-side ILM flap flip line (white arrow) toward the nasal retinal reversal covering the MH (white triangle). (c) The ILM peels off to the edge of the MH. The ILM part facing the vitreous is white, while the ILM part facing the retinal tissue is green. The peripheral parts of the ILM were trimmed. The MH was closed with an inverted ILM flap. The ILM flap facing the vitreous is green, while the ILM flap facing the retinal pigment epithelium is white. This indicates that the ILM flap was inverted and (d) A low-molecular-weight viscoelastic agent was used for fixation (arrow).
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case_images: PMC10798096_04_10.1177_03000605231223635-fig1.jpg
case_images: fig1-03000605231223635
case_images: B-scan ultrasonography showed speckled vitreous body opacity, posterior scleral staphyloma, and superficial retinal detachment (Supplementary Figure S1).
case_images: Patient 1, fundus image before and after left eye surgery. (a) Photograph of the preoperative superficially detached fundus of the macular area (white arrows) and (b) Nineteen months after surgery.
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case_images: Laser fundus photography (Daytona; Optos, Dunfermline, Scotland) showed a tessellated fundus, an atrophic arc next to the optic disc, diffuse atrophy of the posterior polar choroid, and superficial retinal detachment in the macular area (Figure 2(a) and Supplementary Figure S1). Fundus images (ZEISS CLARUS 500; Zeiss Group) showed retinal reattachment with two limited choroidal atrophic plaques at the posterior pole (Figure 2(b)).
case_images: Patient 1, optical coherence tomography images. (a, c-f) Horizontal scan. (b) Vertical scan. (a) Preoperative loss of the full retinal thickness in the macular area, macula hole formation, and retinal detachment. (b) On postoperative day 6, the macular hole margin was connected by an inverted limiting membrane flap bridge. (c) Twenty-three days after surgery, the integrity of the nerve fiber layer of the central retina of the macula was restored. The retina was still detached. (d) Eighty-three days after surgery, the center of the macula was completely reduced, and the retinal temporal side had persistent subretinal fluid. (e) A small amount of subretinal fluid remained on the temporal side of the retina 18 months after surgery and (f) One month after silicone oil removal (approximately 19 months after application of the temporal inverted limiting membrane flap), the retina was completely reduced, the subretinal fluid had disappeared, and the macular fovea was formed.
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case_images: OCT showed separation of the macular neuroretina from the pigmented epithelial layer (Figure 3(a)). One month after surgery (about 19 months after ILM reversal), the retina was completely reduced and the macular fovea was formed (Figure 3(f)). The contraction and fusion of residual Muller cell structures in the flipped ILM valve led to closure of the bridging hole (Figure 3(d)).
case_images: PMC10798096_02
case_images: Schematic diagram of temporal inverted limiting membrane (ILM) flap technique. (a) After creating a semicircular ILM notch (blue arrow) from the temporal edge of the macular hole (MH) (red circle), the indocyanine green-stained ILM flap that formed on the temporal side of the macula was flipped toward the nasal side (blue dotted arrow) to cover the MH completely. (b) Cross-sectional view of the temporal inverted ILM flap technique (intraoperative optical coherence tomography). The figure shows the temporal-side ILM flap flip line (white arrow) toward the nasal retinal reversal covering the MH (white triangle). (c) The ILM peels off to the edge of the MH. The ILM part facing the vitreous is white, while the ILM part facing the retinal tissue is green. The peripheral parts of the ILM were trimmed. The MH was closed with an inverted ILM flap. The ILM flap facing the vitreous is green, while the ILM flap facing the retinal pigment epithelium is white. This indicates that the ILM flap was inverted and (d) A low-molecular-weight viscoelastic agent was used for fixation (arrow).
case_images: 10.1177_03000605231223635-fig1.jpg
case_images: PMC10798096_04_10.1177_03000605231223635-fig1.jpg
case_images: fig1-03000605231223635
case_images: B-scan ultrasonography showed speckled vitreous body opacity, posterior scleral staphyloma, and superficial retinal detachment (Supplementary Figure S1).
case_images: Patient 2. (a) Heidelberg laser fundus photography before surgery. Postoperative optical coherence tomography image (horizontal scan). (b) On the fourth day, the hole was still visible; the maximum diameter above the hole was 797 microm. (b) The inverted limiting membrane was flipped to the inside of the macular hole; the inverted limiting membrane fold (white arrow) was visible, and the retina was completely reduced. (c) On day 14, the macular hole had basically disappeared, and the macular center was connected by hyperreflective matter. (d) On day 52, the macular hole had healed, and the outer retinal layer in the center of the fovea was missing and (e) Formation of the outer retinal layer was seen in the fovea 3 months after surgery.
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case_images: Fundus photography showed a tessellated fundus, an atrophic arc next to the optic disc, diffuse atrophy of the posterior polar choroid, and superficial retinal detachment in the macular area and MHs (Figure 4 and Supplementary Figure S1). At 3 months, fovea formation of the outer layer of the retina was observed (Figure 4(e)). A flipped ILM was observed lining the inner wall and bottom of the MHRD (Figure 4(b)), and both sides of the retinal nerve tissue extended into the hole, resulting in complete healing of the hole.
case_images: PMC10798096_03
case_images: Schematic diagram of temporal inverted limiting membrane (ILM) flap technique. (a) After creating a semicircular ILM notch (blue arrow) from the temporal edge of the macular hole (MH) (red circle), the indocyanine green-stained ILM flap that formed on the temporal side of the macula was flipped toward the nasal side (blue dotted arrow) to cover the MH completely. (b) Cross-sectional view of the temporal inverted ILM flap technique (intraoperative optical coherence tomography). The figure shows the temporal-side ILM flap flip line (white arrow) toward the nasal retinal reversal covering the MH (white triangle). (c) The ILM peels off to the edge of the MH. The ILM part facing the vitreous is white, while the ILM part facing the retinal tissue is green. The peripheral parts of the ILM were trimmed. The MH was closed with an inverted ILM flap. The ILM flap facing the vitreous is green, while the ILM flap facing the retinal pigment epithelium is white. This indicates that the ILM flap was inverted and (d) A low-molecular-weight viscoelastic agent was used for fixation (arrow).
case_images: 10.1177_03000605231223635-fig1.jpg
case_images: PMC10798096_04_10.1177_03000605231223635-fig1.jpg
case_images: fig1-03000605231223635
case_images: B-scan ultrasonography showed speckled vitreous body opacity, posterior scleral staphyloma, and superficial retinal detachment (Supplementary Figure S1).
case_images: Patient 3. Optical coherence tomography images. (a-c) Horizontal scan. (d) Vertical scan. (a) Before surgery, the maximum diameter of the hole was 598 microm. (b) On day 25 after surgery, the hole was closed and the fovea was well formed and (c, d) Two months after surgery, hyperplasia was observed under the internal limiting membrane, the spaces below the internal limiting membrane remained. The central fovea outer collagenous layer was connected, and the external limiting membrane and ellipsoid zone were restored.
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case_images: At 2 months, hyperplasia was observed under the ILM, the spaces below the ILM remained, the central fovea outer collagenous layer was connected, and the ELM and EZ were restored (Figure 5(c), (d)).
case_images: PMC10798096_04
case_images: Schematic diagram of temporal inverted limiting membrane (ILM) flap technique. (a) After creating a semicircular ILM notch (blue arrow) from the temporal edge of the macular hole (MH) (red circle), the indocyanine green-stained ILM flap that formed on the temporal side of the macula was flipped toward the nasal side (blue dotted arrow) to cover the MH completely. (b) Cross-sectional view of the temporal inverted ILM flap technique (intraoperative optical coherence tomography). The figure shows the temporal-side ILM flap flip line (white arrow) toward the nasal retinal reversal covering the MH (white triangle). (c) The ILM peels off to the edge of the MH. The ILM part facing the vitreous is white, while the ILM part facing the retinal tissue is green. The peripheral parts of the ILM were trimmed. The MH was closed with an inverted ILM flap. The ILM flap facing the vitreous is green, while the ILM flap facing the retinal pigment epithelium is white. This indicates that the ILM flap was inverted and (d) A low-molecular-weight viscoelastic agent was used for fixation (arrow).
case_images: 10.1177_03000605231223635-fig1.jpg
case_images: PMC10798096_04_10.1177_03000605231223635-fig1.jpg
case_images: fig1-03000605231223635
case_images: B-scan ultrasonography showed speckled vitreous body opacity, posterior scleral staphyloma, and superficial retinal detachment (Supplementary Figure S1).
case_images: Patient 4. (a) Fundus photography shows a tessellated fundus, diffuse atrophy of the posterior polar choroid, and a macular white hole. (b) On day 20, fundus photography showed good retinal reattachment and diffuse choroidal atrophy at the posterior pole and white fundus. (c) Optical coherence tomography showed preoperative retinal detachment and (d) Twenty days after surgery, hole closure and scarring were evident below the poor foveal morphology.
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case_images: Heidelberg laser fundus photography showed a tessellated fundus, diffuse atrophy of the posterior polar choroid, and a macular white hole (i.e., localized area of the sclera appearing white, making it difficult to observe retinal fissures against the white background) (Figure 6(a)). On postoperative day 20, the retina was well reduced, and diffuse choroidal atrophy and a white appearance were observed in the posterior pole of the fundus (Figure 6(b)).