A preliminary report on a new surgical technique: non-peeling internal limiting membrane relaxation for myopic macular schisis

Dear Editor, Pathologic myopia (PM) is a major cause of irreversible blindness worldwide, with a particularly high prevalence in Asian populations.[1] Among the ocular complications associated with pathological myopia, macular schisis holds particular importance. It develops due to underlying structural issues – namely, posterior staphyloma and vitreoretinal interface traction – and is a well-documented and not uncommon occurrence in the PM patient population.[2] As the axial length abnormally increases, severe separation between retinal layers leads to visual distortion and decline, making it a typical manifestation of pathologic myopia traction maculopathy (MTM).[3] The core of its surgical management centers on the strategic handling of the internal limiting membrane (ILM)[4] While traditional complete ILM peeling effectively relieves traction, it is associated with limitations such as a high risk of iatrogenic macular hole (MH) and potential damage to crucial retinal cells like Müller cells . Fovea-sparing ILM peeling, though an alternative, presents significant technical challenges, limiting its widespread clinical application. Consequently, there is a pressing need for a novel surgical technique that can achieve precise traction release while maximizing the protection of the retinal microstructure. Here, we report a case of pathologic MTM treated with a new technique – the “Internal Limiting Membrane Circular Relaxing Incision.” The patient was a 52-year-old female with a history of high myopia (axial length 29.72 mm in the left eye), who presented with a 3-year history of metamorphopsia and a 1-week sudden visual decline in her left eye. The preoperative best-corrected visual acuity (BCVA) in the left eye was 0.15. Fundus photography revealed tessellated fundus changes typical of high myopia in both eyes, with vitreous hemorrhage in the left eye. Optical coherence tomography (OCT) confirmed a diagnosis of pathologic MTM (Fig. 1A). The key innovation of our surgical technique lies in the following step: after performing a standard vitrectomy, instead of completely peeling the ILM, a circumferential relaxing incision was made along the inner vascular arcade in the macular area using a membrane scraper (Fig. 1B). This maneuver mechanically interrupts the tangential tension ring of the ILM, directly targeting the transmission pathway of pathological traction while preserving the integrity of the ILM in the foveal region. Postoperative follow-up showed a continuous improvement in the patient’s BCVA from 0.15 preoperatively to 0.6 at 3 months postoperatively (Fig. 1C). OCT imaging confirmed the near-complete resolution of the inner layer schisis and significant reduction of the outer layer schisis, indicating effective restoration of the retinal anatomy. No complications, such as MH, occurred, supporting the feasibility of this technique. The core advantage of this “circular relaxing incision” technique lies in its unification of biomechanical innovation and structural preservation. First, its design is based on the biomechanical property of the ILM as the retinal layer with the poor extensibility. The circular incision directly disrupts the transmission chain of traction forces, achieving “precise tension release” rather than “indiscriminate peeling,” thereby theoretically avoiding the extensive damage to the inner retinal structures associated with traditional methods. Second, the preservation of the foveal ILM integrity significantly reduces the risk of iatrogenic MH and provides a more favorable microenvironment for photoreceptor functional recovery, which is particularly beneficial for fragile maculas with concomitant high myopic atrophy. Furthermore, this technique offers a higher degree of procedural standardization compared to fovea-sparing internal limiting membrane peeling (FSIP), significantly lowering the technical barrier and making it more suitable for widespread adoption, aligning with the trend of expanding access to specialized care. Figure 1.: Case presentation of internal limiting membrane circular relaxing incision for myopic macular schisis. A. Preoperative ophthalmic examination. Fundus photographs of both eyes and horizontal cross-sectional optical coherence tomography scans of the macular area. B. Key schematic of the surgical procedure. The green circle indicates the target area. The red arc line illustrates the site of the circumferential relaxing incision made along the inner vascular arcade of the macula. C. Postoperative follow-up results. Upper panel: line graph showing the trend of best-corrected visual acuity in the left eye preoperatively and at 1 week, 1 month, and 3 months postoperatively. Lower panel: Corresponding serial horizontal optical coherence tomography scans of the macular area at the same time points. We have initiated a prospective single-center cohort study at our institution to compare this technique with traditional complete ILM peeling and FSIP. In the future, integrating artificial intelligence for preoperative planning and intraoperative navigation may further optimize the location and extent of the incision, enabling personalized “biomechanical modulation.” In summary, this report is the first to propose the “Internal Limiting Membrane Circular Relaxing Incision” as a targeted surgical approach for pathologic MTM. By innovating the biomechanical mechanism, it balances efficacy and safety, offering a new direction for minimally invasive retinal surgery. Its personalized application value requires validation through larger sample sizes and longer-term follow-up studies.