Inverted ILM flap technique showed superior visual acuity compared to complete ILM removal in large macular holes.

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Frontiers in Medicine Published April 16, 2026 Medically reviewed April 25, 2026 Study authors: Xiang-Yue Zheng, De-Jin Cheng, Xiao-Yi Yu, Ze-Feng Xiao DOI ↗ By Dr. Lars van Dijk, PhD · Surgical, Procedural & Diagnostic

Key Takeaway

Consider that inverted ILM flap may offer visual acuity benefits over complete removal in large macular holes, though data is limited.

This retrospective cohort study examined 56 patients with large macular holes (>400 µm) treated via either an inverted internal limiting membrane (ILM) flap technique or complete ILM removal. The primary outcome was best-corrected visual acuity (BCVA), with secondary outcomes including restoration of the external limiting membrane (ELM) and ellipsoid zone (EZ). Outcomes were assessed at 3 and 6 months post-surgery.

Analysis revealed that BCVA, ELM, and EZ recovery were better in the Hole-door group compared to the Negative group, with a P value less than 0.05. However, for macular holes possessing Hole-door structures, BCVA and ELM/EZ restoration were similar between ILM removal and ILM flap groups at six months (P > 0.05). In other subgroup comparisons, BCVA was significantly better in the ILM flap group than the ILM removal group (P < 0.05), and Group 2-b (ILM flap) outperformed Group 2-a (ILM removal) regarding BCVA and membrane restoration (P < 0.05).

Regarding safety, no adverse events, serious adverse events, discontinuations, or tolerability data were reported in the study. The study limitations include a small sample size of 56 patients, a lack of reported funding or conflicts of interest, and the absence of detailed absolute numbers for outcomes. Furthermore, the study phase and publication type were not reported. Consequently, while the inverted ILM flap technique demonstrated superior visual outcomes in certain contexts, the evidence is limited by its observational design and incomplete reporting.

Study Details

Study typeCohort

EvidenceLevel 3

PublishedApr 2026

View Original Abstract ↓

To compare the anatomical and functional outcomes of the inverted internal limiting membrane (ILM) flap technique and the complete ILM removal in the treatment of large macular hole (MH) > 400 μm with or without Hole-door structures. This retrospective study analyzed 56 patients with MH > 400 μm. Based on hole edge morphology evaluated by archived intraoperative optical coherence tomography (iOCT) images, patients were divided into the Hole-door group (Group 1) and the Negative group (Group 2). Within each group, patients were further classified into two subgroups based on the surgical technique performed: complete ILM removal (Group 1-a, 2-a) and visco-assisted ILM flap (Group 1-b, 2-b). External limiting membrane (ELM) and ellipsoid zone (EZ) restoration and best-corrected visual acuity (BCVA) were assessed at 3 and 6 months post-surgery. Correlation analysis found no significant link between preoperative MHD and postoperative outcomes. The Hole-door group showed better vision, ELM, and EZ recovery than the Negative group, regardless of ILM removal or visco-assisted ILM flap (P < 0.05). In evaluating the prognoses between both techniques for macular holes with or without Hole-door structures, at 6 months, BCVA and ELM/EZ restoration were similar in Groups 1-a and 1-b (P > 0.05), but at 3 months, Group 1-b showed better results (P < 0.05). In the negative subgroups, Group 2-b outperformed Group 2-a in BCVA and ELM and EZ restoration at 6 months (P < 0.05) and in BCVA and ELM restoration at 3 months, though not in EZ restoration (P Large macular holes with Hole-door structures have a better prognosis than those without. In these cases, BCVA and retinal microstructure restoration are similar between ILM removal and ILM flap surgery, but the ILM flap accelerates recovery.