Yin-Yang Staining Technique to Create a Nonstained Internal Limiting Membrane Flap to Cover Large Idiopathic Macular Holes

Abstract

Purpose: To describe a modified technique for negative and positive (Yin-Yang) staining of the internal limiting membrane (ILM) to create a nonstained ILM flap that covers large idiopathic macular holes (MHs). Methods: Consecutive patients with large idiopathic MHs (>400 μm) were prospectively included in the study. After the central vitreous was removed, a droplet of triamcinolone acetonide was injected, covering the MH and surrounding area. Subsequently, indocyanine green (ICG) was injected to stain the outer area of the ILM, followed by creation of a flap from the temporal stained area. Finally, the nonstained ILM flap was inverted to cover the MH. The main outcomes included the best-corrected visual acuity (BCVA), macular contour, and integrity of the outer retina. Results: This study comprised 31 patients (31 eyes). Of the eyes, 28 (90.3%) achieved primary MH closure. The mean minimum linear diameter and base diameter of the MH were 593 ± 119 μm and 1082 ± 242 μm, respectively. At the 6-month follow-up, 12 eyes (38.7%) and 9 eyes (29.0%) had regained a U-shaped or V-shaped macular contour, respectively. In addition, the mean logMAR BCVA improved from 1.06 ± 0.30 preoperatively to 0.56 ± 0.31 (P < .001). Twenty-one eyes (67.7%) and 16 eyes (51.6%) had regained integrity of the external limiting membrane and ellipsoid zone, respectively, at the 6-month follow-up. Conclusions: The modified ILM staining technique using triamcinolone acetonide and ICG sequentially is a safe and effective method of creating a nonstained ILM flap that covers large MHs and prevents the foveal area from coming into direct contact with ICG.

Keywords: idiopathic macular hole; indocyanine green; internal limiting membrane; staining; triamcinolone acetonide.

Figure 1.

Key steps of the Yin-Yang ILM staining technique. (A) After the posterior vitreous and central vitreous are removed, the vitreous cavity is filled with balanced saline solution. (B) A droplet of triamcinolone acetonide is injected onto the posterior pole to cover the MH and its surrounding area. (C) Dextrose-diluted ICG is injected around the triamcinolone acetonide–covered area for ILM staining. (D) After sequential clearance of the ICG and triamcinolone acetonide, the area covered by the triamcinolone acetonide droplet is not stained by the ICG, while the peripheral area of ILM is well stained. (E) A pinch-peel technique is used to create an ILM flap from the stained area. (F) The wide-base flap is inverted with an intraocular forceps to cover the MH with its nonstained central part. Abbreviations: ICG, indocyanine green; ILM, internal limiting membrane; MH, macular hole.

Figure 2.

Preoperative optical coherence tomography images and different stages of the ILM flaps, macular contour, and integrity of the outer retina 1 month postoperatively. (A1 and A2) The MH has regained a V-shaped closure, the ILM flap does not completely cover the foveal area (red arrow), and the ELM is intact; however, the EZ still shows slight discontinuity. (B1 and B2) The MH has regained a U-shaped closure, the ILM flap is visible (red arrow), and the outer retina has almost realigned. (C1 and C2) The MH has regained a V-shaped closure, the ILM flap completely covers the foveal area (red arrow), and the outer retina has almost realigned. Abbreviations: ELM, external limiting membrane; EZ, ellipsoid zone; ILM, internal limiting membrane; MH, macular hole.

Figure 3.

Number and percentage of patients with realignment of the external limiting membrane (ELM) and ellipsoid zone (EZ) 1 month, 3 months, and 6 months postoperatively.