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Purpose. To assess the safety and effectiveness of the single-layered inverted internal limiting membrane (ILM) flap technique for treating chronic, large, or highly myopic macular holes (MHs). Methods. The medical records of 20 eyes of 20 consecutive Japanese patients with large MHs n=6 (minimal diameter, >400 μm), chronic MHs n=2 (symptom duration, >24 months), MHs in high myopia n=11 (axial length, >26 mm), and MHs in a patient unable to maintain prone positioning postoperatively n=1 were reviewed retrospectively. All patients underwent 25-gauge pars plana vitrectomy and the temporal inverted ILM flap technique. A semicircular ILM notch was made temporally two disc diameters from the MH using a 25-gauge knife, and the ILM was peeled temporally to create a semicircular ILM flap using a 25-gauge forceps. The single-layered ILM flap was inverted in a nasal direction to cover the MH. When an epiretinal membrane (ERM) was present, it was peeled before the ILM flap was inverted. Results. The MHs closed successfully in all (100%) eyes postoperatively. In the MHs associated with an ERM, after hole closure, gradual foveal deformation occurred in both the area from which the ILM was not peeled and the ILM flap inverted side. Conclusions. The single-layered inverted ILM flap technique, a simple surgery to treat MHs, provides scaffolding for retinal gliosis and may facilitate bridge formation between the walls of the MH under the flap. Considering the 100% success rate of MH closure, this technique seems to be effective and safe for treating chronic, large, or highly myopic MHs and MHs in patients unable to maintain postoperative prone positioning. In the MHs associated with ERMs, gradual foveal deformation was observed after ERM peeling. Further studies are needed to minimize surgical complications and understand the mechanism of this technique. This trial is registered with UMIN000035091.

The Role of Single-Layered Flap in Temporal Inverted Internal Limiting Membrane Flap Technique for Macular Holes: Pros and Cons