Comparative visual outcomes of inverted ILM flap “covering” versus “stuffed” techniques for macular hole surgery

Purpose To compare the functional and anatomical outcomes of the inverted internal limiting membrane (ILM) flap covering and stuffed techniques in primary macular hole (MH) surgery. Methods This retrospective case series included 57 eyes that underwent inverted ILM flap surgery by a single surgeon (covering, n = 33; stuffed, n = 24). Best-corrected visual acuity (BCVA) and optical coherence tomography findings, including restoration of the external limiting membrane (ELM) and ellipsoid zone (EZ), were assessed preoperatively and at 1 and 6 months postoperatively. Results There were no significant differences in preoperative characteristics or MH closure rates between groups. BCVA improved significantly in both groups postoperatively; however, BCVA was significantly better in the covering group at 1 month ( P = 0.005) and 6 months ( P = 0.001). Restoration of the ELM and EZ was more frequent in the covering group at 1 month (ELM, P < 0.001; EZ, P = 0.002) and 6 months (ELM, P < 0.001; EZ, P = 0.001). Conclusion Although both techniques achieved comparable anatomical closure, the covering method provided superior visual and outer retinal recovery for a wide range of macular holes, including medium-to-large cases. These findings suggest that the covering technique may be preferable as a standard approach for primary MH surgery.