Internal Limiting Membrane Free Flap Transposition and tuck technique for treatment of chronic full thickness macula hole

Abstract

Purpose: To review the effect of internal limiting membrane (ILM) free-fl ap transposition with tuck technique in chronic full-thickness macula holes after previously failed vitrectomy. METHOD: Consecutive patients with chronic full thickness macula hole (FTMH) of at least 1 year after failed initial vitrectomy and macula hole surgery were recruited for free flap internal limiting membrane (ILM) transposition without the aid of adjunct intraoperative tamponade. Technique: (No vitrectomy needed as all cases were previously vitrectomized) 3 port 25G Constellation® vision system, Alcon and Leica Provea microsystem ILM free flap peeled around arcades or where available with an 25G ILM forcep after staining with Membraneblue dual, DORC® ILM flap size should be around 1.5 times the diameter of the macula hole Overly large flaps will cause redundancy Flap is tucked at the distal margin first and the remaining flap placed over hole A sticky flap may be freed from the forceps by gently nudge around hole or the assistance of the light pipe The remaining flap is tucked with a closed ILM forcep in 360 degree fashion, avoiding any contact with the RPE below (without viscoelastic, blood, PFCL or other means of tamponade) Fluid air exchange is performed with a soft tip avoiding turbulence near the free flap C3F8 gas used as tamponade and patient put into a prone position for 2 weeks RESULTS: 6 cases were recruited, 4 female / 2 male, 4 Right eye / 2 Left eye Average Age: 65 (56-72 years old) Average Macula hole duration AFTER first PPV: 953 days (399 to 1013 days) Average Macula hole size preoperatively: 0.838 mm (340um to 1370um) Conclusion: We achieved a 83.33% closure rate in previously failed full thickness macula hole surgery which remained opened an average of 953 days. The eye with a failed closure had the longest chronicity of 2349 days post initial surgery and extreme myopia of >33mm axial length. Although the surgery is challenging, from this case series, free flap ILM transposition without the assistance to adjunct tamponade is effective in treating chronic FTMH.