Simple Superior Inverted Flap Technique with Extended Internal Limiting Membrane Peeling for the Treatment of Large Macular Holes

Purpose: To evaluate the anatomical and functional outcomes of a simplified superior inverted internal limiting membrane (ILM) flap technique with extended ILM peeling for the surgical treatment of large idiopathic macular holes (iMH). Patients and Methods: This retrospective, non-randomized, interventional consecutive case series included 42 eyes of 40 patients with iMH. Patients were grouped according to the CLOSE study classification: Group 1: large holes (n=19, minimum linear diameter [MLD] > 400 to ≤ 550 μm), Group 2: extra-large holes (n=18, MLD > 550 to ≤ 800 μm), and Group 3: XXL holes (n=5, MLD > 800 to ≤ 1000 μm). The mean follow-up time was 20.63 ± 18.32 months. The primary endpoint was MH closure rate. Secondary outcomes included closure type, changes in best-corrected visual acuity (BCVA), ellipsoid zone (EZ) defect, flap position, and surgical complications. Results: Anatomical type 1 closure was achieved in all 42 eyes (100%). The proportion of favorable U-shaped closure decreased significantly with increasing hole size (χ 2 = 9.26, df = 2, p = 0.010), with rates of 84.2%, 81.3%, and 20.0% in Groups 1, 2, and 3, respectively. BCVA and EZ defect improved significantly over time in all groups. Final BCVA gain was 4.4 ± 3.3, 6.2 ± 2.7, and 7.3 ± 4.7 ETDRS lines in Groups 1, 2, and 3, respectively, without significant inter-group differences (p > 0.05). Final BCVA correlated with preoperative BCVA (r = 0.51, p < 0.001) and final EZ defect (r = 0.39, p = 0.013), but not with iMH size or symptom duration (p > 0.05). No major complications were observed. Conclusion: The described surgical technique, involving the combination of a superior inverted ILM flap with extended ILM peeling and minimal manipulation of the posterior pole is highly effective in achieving anatomical and functional success in large iMHs up to 1000 μm, with a favorable safety profile and consistent structural recovery.