Combined Macular Hole Surgery Improves Outcomes in Patients With High Myopia

Patients with high myopia who experience a macular hole should be considered for a combined surgical approach.

Combining internal limiting membrane (ILM) flap inversion with macular buckling can help patients with high myopia achieve better postoperative best-corrected visual acuity (BCVA) and a higher success rate of macular hole (MH) than those treated with buckling alone, according to a report published in Eye.

Researchers recruited individuals with full-thickness MH macular detachment (FTMH-MD) caused by long axial lengths longer than 26.5 mm, with spherical equivalent refraction worse than -8.0 diopters (D). Exclusion factors included retinal detachment outside vascular arcades, glaucoma, or ocular trauma. This prospective analysis took place at a large ophthalmic center in China, from January 2017 to November 2019. Sixty-two participants, between 18 and 70 years of age, were randomly assigned to 1 of 2 groups; 33 eyes in the macular buckling standalone cohort, and 29 eyes in the combined surgery group.

At 24 months, mean best-corrected visual acuity (BCVA) improved significantly after macular buckling-only (P =.027) and combination procedure (P <.001). BCVA of dual surgery patients proved significantly better than those with standalone buckling at 12 months (P =.021) and 24 months (P =.041). Further, 97.0% undergoing buckling-only achieved successful retinal reattachment, as well as 100% undergoing ILM flap plus buckling. MH closure occurred for 66.7% receiving standalone buckling and 82.8% with the dual method. The researchers note successful flap inversion was formed in 69.0% of eyes — but 100% of these attained hole closure.

In buckling-only patients, the retina potentially reattached from “scleral imbrications,” and full-thickness hole closed by accumulation of activated glial cells with time, according to the study. “In combined surgery, the mechanism of MH closure was different, as the inverted ILM flap formed a bridge that provided a scaffold for cells to encroach and enclose the hole,” according to the report. “Then, the subretinal fluid was absorbed gradually, and the retina was reattached.” With dual surgery, reattachment and MH closure occurred sooner.

In combined surgery, the mechanism of MH closure was different, as the inverted ILM flap formed a bridge that provided a scaffold for cells to encroach and enclose the hole.

The most frequently reported complications were diplopia and metamorphopsia, and these disturbances decreased or resolved with time. Three individuals in the standalone set and 2 receiving dual surgery experienced postoperative intraretinal cysts, and there was 1 case of choroidal neovascularization — origins for these were uncertain. Previous research suggests inverted ILM flaps may also cause elevated gliosis. Gliosis can result in irregular retinal surfaces, and metamorphopsia. Alternatively, in a meta-analysis, the flap approach realihadzed a MH closure rate of 91.8% to 97.1%, identifying a beneficial option in high myopia with or without retinal detachment.

No significant differences in BCVA arose during the current study when comparing eyes with MH closure and those without (P >.05), a finding also shown in prior studies. Other reports indicate MH closure may lower chances for later retinal detachments, so the current investigation advises combination surgery in cases of high myopia and MH-MD.

Limitations of this analysis include a small sample at a single site, no significant difference in BCVA among those with closed or unclosed MH, and that ILM flap involving thin tissue found with high myopia is technically difficult even for accomplished surgeons. Conversely, a strength was the 2-year surgical follow-up.


Zhao X, Song H, Tanumiharjo S, et al. Macular buckling alone versus combined inverted ILM flap on macular hole-associated macular detachment in patients with high myopia. Eye. Published online on January 31, 2023. doi:10. 1038/s41433-023-02406-1