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Background: Macular hole (MH) is a full-thickness defect in the central portion of the retina that causes loss of central vision. According to the usual definition, a large MH has a diameter greater than 400 µm at the narrowest point. For closure of MH, there is evidence that pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling achieves better anatomical outcomes than standard PPV. PPV with ILM peeling is currently the standard of care for MH management; however, the failure rate of this technique is higher for large MHs than for smaller MHs. Some studies have shown that the inverted ILM flap technique is superior to conventional ILM peeling for the management of large MHs., Objectives: To evaluate the clinical effectiveness and safety of pars plana vitrectomy with the inverted internal limiting membrane flap technique versus pars plana vitrectomy with conventional internal limiting membrane peeling for treating large macular holes, including idiopathic, traumatic, and myopic macular holes., Search Methods: The Cochrane Eyes and Vision Information Specialist searched CENTRAL, MEDLINE, Embase, two other databases, and two trials registries on 12 December 2022., Selection Criteria: We included randomized controlled trials (RCTs) that evaluated PPV with ILM peeling versus PPV with inverted ILM flap for treatment of large MHs (with a basal diameter greater than 400 µm at the narrowest point measured by optical coherence tomography) of any type (idiopathic, traumatic, or myopic)., Data Collection and Analysis: We used standard methodological procedures expected by Cochrane and assessed the certainty of the body of evidence using GRADE., Main Results: We included four RCTs (285 eyes of 275 participants; range per study 24 to 91 eyes). Most participants were women (63%), and of older age (range of means 59.4 to 66 years). Three RCTs were single-center trials, and the same surgeon performed all surgeries in two RCTs (the third single-center RCT did not report the number of surgeons). One RCT was a multicenter trial (three sites), and four surgeons performed all surgeries. Two RCTs took place in India, one in Poland, and one in Mexico. Maximum follow-up ranged from three months (2 RCTs) to 12 months (1 RCT). No RCTs reported conflicts of interest or disclosed financial support. All four RCTs enrolled people with large idiopathic MHs and compared conventional PPV with ILM peeling versus PPV with inverted ILM flap techniques. Variations in technique across the four RCTs were minimal. There was some heterogeneity in interventions: in two RCTs, all participants underwent combined cataract-PPV surgery, whereas in one RCT, some participants underwent cataract surgery after PPV (the fourth RCT did not mention cataract surgery). The critical outcomes for this review were mean best-corrected visual acuity (BCVA) and MH closure rates. All four RCTs provided data for meta-analyses of both critical outcomes. We assessed the risk of bias for both outcomes using the Cochrane risk of bias tool (RoB 2); there were some concerns for risk of bias associated with lack of masking of outcome assessors and selective reporting of outcomes in all RCTs. All RCTs reported postoperative BCVA values; only one RCT reported the change in BCVA from baseline. Based on evidence from the four RCTs, it is unclear if the inverted ILM flap technique compared with ILM peeling reduces (improves) postoperative BCVA measured on a logarithm of the minimum angle of resolution (logMAR) chart at one month (mean difference [MD] -0.08 logMAR, 95% confidence interval [CI] -0.20 to 0.05; P = 0.23, I 2 = 65%; 4 studies, 254 eyes; very low-certainty evidence), but it may improve BCVA at three months or more (MD -0.17 logMAR, 95% CI -0.23 to -0.10; P < 0.001, I 2 = 0%; 4 studies, 276 eyes; low-certainty evidence). PPV with an inverted ILM flap compared to PPV with ILM peeling probably increases the proportion of eyes achieving MH closure (risk ratio [RR] 1.10, 95% CI 1.02 to 1.18; P = 0.01, I 2 = 0%; 4 studies, 276 eyes; moderate-certainty evidence) and type 1 MH closure (RR 1.31, 95% CI 1.03 to 1.66; P = 0.03, I² = 69%; 4 studies, 276 eyes; moderate-certainty evidence). One study reported that none of the 38 participants experienced postoperative retinal detachment., Authors' Conclusions: We found low-certainty evidence from four small RCTs that PPV with the inverted ILM flap technique is superior to PPV with ILM peeling with respect to BCVA gains at three or more months after surgery. We also found moderate-certainty evidence that the inverted ILM flap technique achieves more overall and type 1 MH closures. There is a need for high-quality multicenter RCTs to ascertain whether the inverted ILM flap technique is superior to ILM peeling with regard to anatomical and functional outcomes. Investigators should use the standard logMAR charts when measuring BCVA to facilitate comparison across trials., (Copyright © 2023 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.)

Purpose: To determine the types of macular holes encountered during vitrectomy for complicated cases of diabetic retinopathy., Methods: This is a retrospective study of consecutive cases of macular holes diagnosed either before or during pars plana vitrectomy for complications of proliferative diabetic retinopathy over a 6-year period. The morphology of these holes is described. Possible mechanisms of their development, surgical considerations, and results after a follow-up of at least 3 months are discussed., Results: Nineteen consecutive cases of macular holes associated with proliferative diabetic retinopathy were reviewed over a 6-year period. Five cases were lamellar and 14 were full thickness. The 14 cases of full thickness macular holes occurred in patients with the following conditions: tractional rhegmatogenous retinal detachment (5); tractional retinal detachment (3); premacular hemorrhage (3); and cystic macular edema (3). Closure of the full thickness holes was achieved in 8 of 11 patients who were followed up for at least 3 months. All the patients had visual improvement, but no patient had a visual acuity of better than 20/100., Conclusion: Macular holes may occur in proliferative diabetic retinopathy in different configurations. Full thickness macular holes can be closed in most cases. Functional improvement can be achieved.

The authors discuss the pathogenesis and the method of treatment of a retinal detachment with a macular hole basing on personal material and a review of foreign literature. Personal material consists of 11 eyes in 10 patients operated upon in the University Ophthalmic Department in Munich in the period November 1988--April 1990. In all the cases the primary method of treatment based on vitrectomy performed through the pars plana with a gas tamponade. In 4 cases a reoperation with silicon oil tamponade was necessary. Anatomical reattachment of the retina was achieved in 9 among 11 treated eyes. In 10 cases the visual acuity was 1/50 or better. Five among them showed the visual acuity at last 0.1.