Folding the internal limiting membrane flap under perfluorocarbon liquid in large, chronic and myopic macular holes

  • Tommaso RossiEmail author
  • Carlandrea Trillo
  • Herman D. Schubert
  • Serena Telani
  • Paola Cirafici
  • Daniele Ferrari
  • Guido Ripandelli
Retinal Disorders



The purpose of the present paper is to describe a surgical technique aimed at creating multiple layers of Internal Limiting Membrane (ILM) using Perfluorocarbon Liquid (PFCL) in order to favour the closure of large, chronic and myopic Macular Holes (MH).


Thirty patients belonging to 3 subgroups: large (> 500 μm), chronic (> 12 months) and myopic (> − 9 diopters), MHs, underwent surgery and completed 6 months follow-up. The ILM was engaged and peeled 360° around the MH, hinged to the rim and folded over the hole. A PFCL bubble spanning the vascular arcades was then injected and the ILM is grasped repeatedly to fold the distal edge towards the MH centre, creating multiple ILM layers over the MH.


MH closed in 26/30 cases (86.6%) with no significant difference among subgroups. Vision improved 2.57 ± 1.56 Snellen lines from LogMAR 1.50 ± 1.19 to 1.19 ± 1.32 (p < 0.01). Ellipsoid Zone (EZ) interruption width reduced from 1129 ± 439 μm to 258 ± 507 μm (p < 0.001) and correlated to pattern of MH closure, post-BCVA and line improvement (p < 0.001 in all cases).


The use PFCL allows multiple ILM layers and resulted in a high closure rate. Pattern of MH closure differs from those previously described leaving a plug of ILM tissue that interrupts retinal architecture often only in the inner layers. PFCL gravity and hydrophobicity displace aqueous while the intensely polar opposite faces of the ILM attract each other. The folded ILM plugs MH and bridges the gap and may help glial cell proliferation and migration.


Internal limiting membrane flap Macular hole Perfluorocarbon liquid 


Financial disclosure

None of the authors has any financial interest in the subject matter and there is no conflict of interest. The authors wish to thank the Fondazione Roma for support. The work was completed at IRCCS Policlinico San Martino Hospital.

Compliance with ethical standards

Patients signed informed consent form. All procedures performed in studies involving human participants were in accordance with the ethical standards of the internal IRB of Policlinico San Martino and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Conflict of interest

The authors declare that they have no conflict of interest.

Supplementary material

417_2019_4439_MOESM3_ESM.xlsx (48 kb)
ESM 1 (XLSX 47 kb)


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.IRCCS Ospedale Policlinico San Martino, UOC OculisticaGenoaItaly
  2. 2.Edward Harkness Eye Institute, Columbia Presbyterian Medical CenterColumbia UniversityNew YorkUSA
  3. 3.IRCCS G.B. Bietti Foundation ONLUSRomeItaly

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