Is it necessary to cover the macular hole with the inverted internal limiting membrane flap in macular hole surgery? A case report

Background: To report a case of late closure of idiopathic full-thickness macular hole (FTMH) after vitrectomy with the inverted internal limiting membrane (ILM) technique. Case presentation: A 68-year-old lady with a stage IV FTMH underwent pars plana vitrectomy with 25 gauge plus transconjunctival system, ILM peeling and gas tamponade. The inverted ILM flap technique was adopted, except that no extra surgical manipulation was used to cover the macular hole with the ILM flap. Surgical outcome was monitored with serial optical coherence tomography (OCT). Complete closure of the FTMH with resolution of intraretinal cystic changes was confirmed on OCT at 16 months postoperatively. Visual acuity improved from a baseline level of 0.1 to 0.4. Conclusion: Idiopathic macular hole closure could be delayed to beyond 1 year following the inverted ILM flap technique, especially if the macular hole was not covered with the ILM flap. Not all macular holes that fail to close in the early postoperative period need to be re-operated and there may be no risk of further visual deterioration.