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We would like to highlight in this issue, the case series from Dai et al. on internal limiting membrane (ILM) transplants for unclosed macular holes [1]. Those of us who have tried a free internal limiting membrane (ILM) patch graft will appreciate the challenges that face surgeons performing this type of surgery. Impressive as the results might be, the impact of this publication goes beyond the introduction of a new technique. Let us ‘dissect’ some of the surgical challenges. Firstly, in eyes with a previous extensive ILM peel, harvesting a new suitable sized patch can be problematic. Although there is a limited evidence base to guide us, many surgeons feel that when it comes to ILM peeling, the larger the better [2]. Therefore, when it comes to re-operation, the remaining ILM may only be available near or even beyond the arcade and surgical experience tells us this is usually thin and difficult to peel. Secondly, there is a problem of Bplacing^ the ILM patch near the macular hole. Without any attachment, as is the case with an inverted ILM flap, the gossamer-like ILM patch is unlikely to stay put where it is Bplaced^. The authors describe using the edge of the hole to secure the graft. Previously, Tom Wolfensberger [3] and more recently others [4] have advocated the use of hyaluronate-based viscoelastics to act as an adhesive. It is interesting that Dai et al. also use viscoelastics to cover the macular hole prior to ICG use. It is possible that the viscoelastic was acting as a ‘glue’ to keep the subsequently placed graft in place. Lai et al. have used autologous blood as a glue [5]. The use of perfluorocarbon liquids for a prolonged period during surgery by Park et al. may also have a similar effect [6]. Thirdly, intraocular forceps are designed to be very effective at grasping ILM. They are, however, not as good at letting it go! The act of releasing the free ILM and placing it in the hole as described can therefore be challenging. The authors emphasise that the patch should be tucked in under the edge of the neurosensory rim of the hole to Bhold^ the ILM in place. They acknowledge that occasionally it was necessary to use the light pipe to disengage the ILM from the forceps. If however, the membrane is not secured by the edge of the macular hole or if not adherent to the viscoelastic, it is likely to float away on intraocular currents during or after surgery. Surgical attempts to re-capture a free floating ILM can also be ‘challenging’ if not impossible. Finally, the fluid to air exchange is not simple. The ILM is liable to be aspirated up the extrusion cannula along with the last drop of vitreous cavity fluid, despite all precautions including aspirating well away from the hole, tilting the eye to dry the fovea first and limiting aspirational flow rates with low pressure gradients and the use of narrow bore cannulas. Assuming all these steps go well, there are still many unanswered questions. How big does the ILM graft need to be? Park et al. suggested a patch twice the size of the hole for a free patch [6]. Such a large membrane may be difficult to harvest, depending again on the extent of the first peel. Is it necessary to use the membrane to completely cover the hole (as a ‘lid’)? Certainly this seems to be reasonable if mechanistically the * David Wong shdwong@gmail.com

Free ILM patch transplantation for recalcitrant macular holes; should we save some internal limiting membrane for later?