Internal limiting membrane peeling for large macular hole: Tailoring the rhexis to the shape of the hole

PURPOSE: To report a simple modification of internal limiting membrane (ILM) peeling tailored to the shape of the macular hole to improve the closure rates. METHODS: This is a single-center interventional case series. conducted between 2016 and 2020. The minimum follow-up was 4 months. All surgeries were performed by one surgeon. Twenty consecutive patients (21 eyes) with large idiopathic macular holes (horizontal diameter: ≥600 μm) were enrolled; vertical hole diameters were also measured using spectral-domain optical coherence tomography (OCT). Following vitrectomy, ILM peeling was performed over a horizontally oval area (additional 1 disc-diameter temporally); perfluoropropane gas (C3F8, 15%) tamponade was used. Hole closure and change in best-corrected visual acuity (BCVA) were monitored after absorption of the gas. Preoperative and postoperative visual acuities were compared using paired t-test. IBM SPSS (ver. 26) was used for analysis. RESULTS: The macular holes were horizontally oval rather than circular without exception: mean horizontal and vertical diameters were 714 μm (range: 600–1020 μm) and 602 μm (490–844 μm), respectively. Following vitrectomy, macular hole closure was obtained in 20/21 eyes by the last follow-up (mean: 28 months, median: 34 months; range 4–48 months). Mean Snellen BCVA improved from 20/200 to 20/63 (P < 0.0001). CONCLUSION: All the macular holes in the study were observed to be horizontally oval. A corresponding horizontal enlargement of the ILM rhexis yielded excellent anatomical and satisfactory visual outcomes.