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Comparative Study
. 2025 Apr 8;25(1):182.
doi: 10.1186/s12886-025-04003-0.

A three-step approach versus the inverted internal limiting membrane flap technique in large full thickness macular hole surgery: a comparative study

Dongwei Lai #  1   2   3 , Siao Tang #  4 , Chufeng Gu  1   2   3 , Chunren Meng  1   2   3 , Chunyang Cai  1   2   3 , Shuai He  5   6   7 , Qinghua Qiu  8
Affiliations
Comparative Study

A three-step approach versus the inverted internal limiting membrane flap technique in large full thickness macular hole surgery: a comparative study

Dongwei Lai et al. BMC Ophthalmol. .

Abstract

Objective: To evaluate the anatomical and functional outcomes of our novel surgery (a three-step approach) and the conventional inverted internal limiting membrane flap technique (IFT) in treating large full-thickness macular holes (FTMHs).

Methods: This was a retrospective, consecutive, nonrandomized comparative study of patients who underwent either the novel surgery (n = 27, Group A) or IFT (n = 27, Group B). The main outcomes of MH closure rates and the best corrected visual acuity (BCVA) at 1-, 3-, and 6-month follow-up were compared between the two groups.

Results: At 6 months postoperatively, MH closure was achieved in 24/27 patients in Group A and 22/27 patients in Group B (88.89% vs. 81.48%, P = 0.704) with U-shaped closure rates being significantly higher in Group A (P = 0.029). The average BCVA at month 6 was 0.69 ± 0.38 (LogMAR) in Group A and 0.91 ± 0.39 in Group B (P = 0.015) with the improvement in BCVA being significantly higher in Group A (0.50 ± 0.59 vs. 0.31 ± 0.59, P = 0.045). The recovery rates of ELM were significantly higher in Group A (P = 0.026).

Conclusions: Our three-step approach greatly improves anatomical and functional outcomes compared with IFT. This novel surgery has a dominant advantage in earlier and higher ultimate closure rate, U-type closure rate, and ELM recovery rate, and more importantly, better recovery of BCVA.

Keywords: A three-step approach; FTMH; Functional and anatomical outcome; IFT.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: This study was approved by the Ethics Committee of Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine and was implemented in accordance with the World Medical Association Declaration of Helsinki. The number of the ethical approval document is 2021SQ247, which is registered in Shanghai General Hospital. All patients were informed about the study and signed written informed consent forms before their enrollment. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Closure type after macular hole surgery. (A) Bridge-like closure; (B) V-shaped closure; (C) U-shaped closure; (D) W-shaped closure. (A) A female patient with a minimal inner diameter of 568 μm underwent conventional IFT surgery and received bridge-like closure 1 month after surgery. (B) A female patient with a minimal inner diameter of 737 μm underwent novel surgery with a three-step approach and received V-shaped closure 1 month after surgery. (C) A female patient with a minimal inner diameter of 566 μm underwent novel surgery with a three-step approach and received U-shaped closure 3 months after surgery. (D) A male patient with a minimal inner diameter of 612 μm who underwent conventional IFT surgery received W-shaped closure 3 months after surgery
Fig. 2
Fig. 2
60-year-old patient presented with a large FTMH. (A) Fundus photography at baseline. (B) SD-OCT at baseline showing a minimal inner diameter of 566 μm, combined with a preoperative BCVA of 0.05; (C) SD-OCT at 1 week after surgery showing a U-shape closure of the MH after conducting the novel three-step approach surgery. The foveal hyperreflective tissue by SD-OCT is shown to move closer to the center in the same direction as the operation with the early appearance of a continuous ELM line. (D) SD-OCT at the 3-month follow-up showing a persistent U-shape closure of the MH. Disruption of the EZ (between red arrowheads) remained, while the ELM line was almost complete. (E) SD-OCT at 6 months follow-up showing a persistent U-shape closure of the MH with complete restoration of both the ELM and the EZ lines. The BCVA increased to 0.6
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