Combined 41- gauge surgically induced macular detachment and free internal limiting membrane flap technique for management of refractory full-thickness macular hole

Purpose: To report a case of anatomic closure and functional improvement in a patient affected by refractory full-thickness macular hole (FTMH) undergone a combined 41-gauge (g) surgically induced macular detachment and free internal limiting membrane (ILM) flap technique. Methods: This is a retrospective case-report of a 70-years-olded woman affected by refractory FTMH who referred to Ophthalmology Unit of Guglielmo da Saliceto Hospital, Piacenza (Italy) in April 2023. The patient underwent a combined 41-g surgically induced macular detachment and free ILM flap. Macular detachment was induced by multiple subretinal injections of balanced salt solution (BSS) by 41-g needle through three retinotomies. Spectral-domain optical coherence tomography (SD-OCT) and best-corrected visual acuity (BCVA) were performed preoperatively and postoperatively at 7 th day, 1 st and 6 th month. Results: On 7 th postoperative day, FTMH showed complete closure. BCVA improved from preoperative 20/400 to 20/70 at 6 th postoperative month. Discussion: BSS subretinal injection allowed the mobilization and relaxation of retina at the posterior pole. Although the edges of the hole were still detectable, their diameters were inferior to preoperative measurements. Autologous free ILM flap allowed to fill the residual gap into the hole. Conclusion: The final anatomic closure, and the postoperative functional improvement demonstrated the effectiveness of this approach, supporting its indication for refractory FTHM.