Innovative Non-Inverted ILM Free Flap Covering Technique for Unclosed Macular Hole Repair

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OBJECTIVE: To examine the safety and effectiveness of non-inverted ILM Free Flap combined with the SPOT technique (Sub-Perfluorocarbon liquid (PFCL) injection of Ocular viscoelastic device (OVD) Technique) in the treatment of unclosed macular holes (MHs). DESIGN: Retrospective interventional case series. PARTICIPANTS: Eight patients (8 eyes) with persistent unclosed MHs were treated at a tertiary eye hospital in China from September 2023 to February 2025. All procedures were performed by the same vitreoretinal surgeon (P.Q.Z.). METHODS: Enhanced ILM peeling and a limited ILM flap harvested outside the peeling margin to cover the MH. A combination of PFCL and OVD (SPOT technique) was applied to stabilize the ILM flap. MAIN OUTCOMES AND MEASURES: Primary outcome was anatomical closure of the MH within 1 month postoperatively. Secondary outcomes included best-corrected visual acuity (BCVA) and structural restoration of the external limiting membrane (ELM), outer nuclear layer (ONL), and ellipsoid zone (EZ) on optical coherence tomography (OCT). RESULTS: All MHs achieved anatomical closure within 1 month. U-shaped closure was noted in 6 eyes (75%) and V-shaped in 2 eyes (25%). BCVA improved in all eyes at final follow-up. OCT showed reconstitution of the ELM, ONL, and EZ bands in all cases. CONCLUSIONS: These findings demonstrate that the innovative combination of the non-inverted, single-layered ILM-free flap with the SPOT technique is effective in treating unclosed MH and improving VA. This approach offers a new solution for unclosed MH and its effectiveness needs to be validated by more well-designed research.

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