Evaluation of the upper internal limiting membrane flap technique for surgical closure of medium and large macular holes.

BACKGROUND: Full-thickness macular hole can cause central vision loss, and outcomes depend on hole size and surgical technique. Inverted internal limiting membrane (ILM) flaps were developed to improve closure in larger defects. We evaluated anatomical and functional outcomes of a superiorly based inverted ILM flap. METHODS: Retrospective, single-arm consecutive case series at a tertiary eye center. All consecutive patients underwent pars plana vitrectomy with a superiorly based inverted ILM flap between January 2021 and December 2023. Best-corrected visual acuity (BCVA) and anatomical closure rates were assessed at 12 months postoperatively. Paired Wilcoxon signed-rank testing for BCVA (logMAR) with Hodges-Lehmann median shift and 95% CI were performed. Outcomes were summarized descriptively by MLD strata. RESULTS: Fifty-one eyes (51 patients; mean age 68.7 ± 7.1 years; 9.8% male) were included. The overall anatomical closure rate was 96.1% (49/51). Median BCVA improved from 1.10 (0.80-1.30) to 0.40 (0.20-0.70) logMAR at 12 months (Wilcoxon p < 0.001), with a Hodges-Lehmann ΔBCVA of - 0.60 logMAR (95% CI, - 0.80 to - 0.40). Among eyes with closure (n = 49), type 1 closure was observed in 49/49 (100%). Postoperative foveal contour was U-shaped in 35/49 (71.4%), V-shaped in 5/49 (10.2%), and W-shaped in 9/49 (18.4%). Median BCVA improved from 1.10 (0.80-1.30) to 0.40 (0.20-0.70) logMAR at 12 months (p < 0.001). No intraoperative or postoperative complications were recorded. CONCLUSION: The upper ILM flap technique appears to be a safe and effective surgical option for medium and large FTMHs, offering high closure rates and favorable visual outcomes. Its limited peeling area may minimize surgical trauma while potentially enhancing flap adherence through gravity-assisted positioning, warranting further comparative study.