What is a Macular Hole, and why is it relevant in the context of high myopia?

A Macular Hole (MH) is a break or tear in the macula, the central part of the retina responsible for sharp, detailed vision. High myopia, or severe nearsightedness, can make the eye longer, stretching the retina and making it more prone to developing MHs. This structural change introduces unique surgical challenges, especially due to the presence of posterior staphyloma and tangential forces affecting the retina.

What are ILM peeling and the inverted ILM flap technique?

ILM peeling and the inverted ILM flap technique are two surgical approaches used to treat myopic MH. ILM peeling involves removing the internal limiting membrane (ILM), a thin layer of tissue over the retina, to relieve traction and promote MH closure. The inverted ILM flap technique, particularly used for large MH, involves creating a flap from the ILM and inverting it over the hole to act as a scaffold for healing. The selection of the technique depends on several factors including MH size and surgeon preference.

Which technique is more effective at closing the macular hole?

The inverted ILM flap technique showed a significantly higher anatomical closure rate compared to ILM peeling. The inverted ILM flap group achieved a 100% closure rate, while the ILM peeling group achieved a 66.7% closure rate. This difference suggests that the inverted ILM flap may be more effective in physically closing the MH.

How do these techniques affect the foveal microstructure and visual outcomes?

The study found that the inverted ILM flap technique showed a greater presence of the external limiting membrane (ELM) and ellipsoid zone (EZ) compared to ILM peeling. The ELM and EZ are crucial components for photoreceptor function. However, the inverted ILM flap group also exhibited more gliosis (scarring) in the macular area. Surprisingly, while the presence of ELM and EZ are indicative of better function, there was a negative correlation between visual acuity and hyperreflective foci (HF).

How should patients and surgeons decide between ILM peeling and the inverted ILM flap technique?

The choice between ILM peeling and the inverted ILM flap technique should be based on a comprehensive evaluation of the patient's condition and a discussion with the ophthalmologist. The inverted ILM flap technique may be preferred for achieving higher MH closure rates, especially in cases with large MH. However, the impact on visual acuity involves a complex interplay of foveal microstructure changes, including the presence of gliosis and hyperreflective foci, so it's essential to consider both the anatomical closure and the potential for visual recovery.

Surreal illustration of myopic macular hole surgery

Myopic Macular Hole Surgery: Which Technique Offers Better Vision?

Elliot Brynn in Health & Wellness October 2026 • 4 min read.

"A new study compares ILM peeling with the inverted ILM flap technique for treating myopic macular holes, revealing surprising insights about visual outcomes and recovery."

Macular holes (MH) in highly myopic eyes pose a significant surgical challenge. While vitrectomy, combined with internal limiting membrane (ILM) peeling, has become a standard approach for idiopathic macular holes, treating MH in high myopia requires overcoming unique complexities, including posterior staphyloma and tangential forces on the retina.

The inverted ILM flap technique emerged as a promising alternative, particularly for large MH. However, the debate continues regarding its superiority over ILM peeling, especially concerning foveal microstructure recovery and visual outcomes. Understanding these nuances is crucial for patients and surgeons alike.

This article explores a recent study comparing ILM peeling with the inverted ILM flap technique in patients with highly myopic MH. We'll delve into the findings, focusing on MH closure rates, foveal microstructure changes, and visual acuity outcomes to provide a clearer picture of the benefits and drawbacks of each approach.

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Standard Approach

Standard Surgery and Its Limits

Macular holes in myopic eyes arise from complex tractional forces involving the vitreomacular interface, epiretinal tissue, and progressive scleral ectasia of the posterior globe wall onlinelibrary.wiley.com. Standard macular-hole surgery is pars plana vitrectomy with epiretinal membrane and internal limiting membrane (ILM) peeling, gas endotamponade, and postoperative prone positioning; modern interventions treat more than 90% of macular holes overall link.springer.com. However, a small subset remains challenging, and a 2025 review describes vitrectomy with ILM peeling as the gold standard for holes under 500 μm and for chronic or highly myopic cases, while noting that newer techniques have expanded options surveyophthalmol.com.

History

Milestones in Macular Surgery

Macular holes are full-thickness defects of retinal tissue involving the anatomic fovea and affecting central visual acuity; they were described in medical literature in the late 19th century retinahistory.asrs.org. The history of macular surgery includes the introduction of pars plana vitrectomy and later advances such as macular-hole surgery, internal limiting membrane (ILM) peeling, and membrane dyes link.springer.com. A 2024 review specifically evaluates outcomes of macular-hole surgery from its inception in 1991 dovepress.com.

ILM Peeling vs. Inverted ILM Flap: What the Research Reveals

Surreal illustration of myopic macular hole surgery

A retrospective study published in the British Journal of Ophthalmology investigated the impact of the inverted ILM flap technique on MH closure and foveal recovery in highly myopic eyes. The study compared two groups of patients: one treated with standard ILM peeling (21 eyes) and the other with the inverted ILM flap technique (19 eyes).

Both groups underwent pars plana vitrectomy and gas tamponade. Researchers then meticulously compared MH closure rates, retinal reattachment (in cases with detachment), foveal microstructure restoration (using OCT imaging), and best-corrected visual acuity (BCVA).

Higher Closure Rate: The inverted ILM flap group demonstrated a significantly higher anatomical closure rate (100%) compared to the ILM peeling group (66.7%).
Foveal Microstructure: The inverted ILM flap group showed a greater presence of the external limiting membrane (ELM) and ellipsoid zone (EZ), crucial for photoreceptor function. However, they also exhibited more gliosis (scarring) in the macular area.
Visual Acuity: Postoperative BCVA was better in eyes with ELM and EZ presence and gliosis. Surprisingly, visual acuity was worse in eyes with hyperreflective foci (HF).

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Latest Research

Foveal Recovery After ILM Flap Surgery

The cited studies report that the inverted ILM flap technique can help restore foveal architecture doi.org. One meta-analysis reports that reconstruction of the foveal external limiting membrane (ELM) at three months after surgery may predict later ellipsoid zone (EZ) restoration and potentially improved visual outcomes doi.org. Another cited study found higher rates of ELM and EZ recovery after the inverted ILM flap technique semanticscholar.org.

Counterpoints

Non-closure and Failed Surgery

High myopia is identified as a risk factor for macular-hole non-closure, alongside concomitant macular disease, uveitis, and macular telangiectasia retinatoday.com. For unclosed holes after primary surgery, reported management options include observation, outpatient fluid–gas exchange, or vitrectomy using different ILM approaches and postoperative tamponade choices; the source notes that comparatively little long-term outcome data are available ophthalmologyretina.org. In myopic traction maculopathy, early disease with mild traction may remain stable without surgery, whereas advanced disease may progress sciencedirect.com.

Comparison

Buckling and Vitrectomy in Highly Myopic Eyes

A prospective interventional case series compared macular buckling (MB) with pars plana vitrectomy (PPV) for full-thickness macular holes accompanied by macular detachment in highly myopic eyes pmc.ncbi.nlm.nih.gov. The provided source snippet does not report the comparative results, so it does not establish which procedure achieved better outcomes. A separate 2023 source notes that highly myopic macular holes can cause central vision loss and increase the risk of retinal detachment, and that surgical efficacy and visual outcomes are lower than in non-myopic eyes pmc.ncbi.nlm.nih.gov.

These findings suggest that while the inverted ILM flap technique excels in closing MH, its impact on foveal microstructure and visual outcomes is more nuanced. The presence of gliosis, while seemingly beneficial, and the negative correlation between visual acuity and HF warrants further investigation.

Navigating the Choice: What This Means for Patients

The study underscores the complexity of MH surgery in highly myopic eyes. While the inverted ILM flap technique appears superior for achieving anatomical closure, the impact on visual acuity involves a complex interplay of foveal microstructure changes.

Patients considering MH surgery should discuss these findings with their surgeons, weighing the benefits of a higher closure rate against the potential for gliosis and the uncertain impact on long-term visual outcomes. Understanding the nuances of each technique allows for informed decision-making and realistic expectations.

Further research is needed to fully elucidate the mechanisms underlying foveal recovery after MH surgery and to optimize surgical techniques for achieving both anatomical success and optimal visual function. Future studies should investigate long-term outcomes and explore strategies for minimizing HF formation and managing gliosis.