Staged PFCL-assisted ILM free flap transplantation for refractory macular holes: resolving the mechanical paradox of graft instability

Introduction Primary pars plana vitrectomy with internal limiting membrane (ILM) peeling closes over 90% of idiopathic full-thickness macular holes (MHs), and revision surgery is challenging owing to limited remaining ILM, especially in myopic or extensively peeled eyes. The present study aimed to propose a staged perfluorocarbon liquid (PFCL)-assisted dual-interface stabilization strategy for autologous ILM free flap transplantation in refractory MHs and provide its biomechanical rationale along with prospective pilot clinical validation. Methods This prospective, multi-center interventional case series included five consecutive eyes with refractory full-thickness MHs (mean age 68.3 ± 8.8 years; mean minimum linear diameter 449.2 ± 196.5 μm) following prior pars plana vitrectomy with ILM peeling and gas tamponade. The framework consisted of (1) placement of an ophthalmic viscoelastic device (OVD) plug within the MH, (2) limited PFCL stabilization, (3) ILM flap preparation outside the PFCL meniscus to preserve membrane mobility, and (4) secondary PFCL expansion before fluid–air exchange. Anatomical closure and best-corrected visual acuity (BCVA) were evaluated during at least 3 months of follow-up. Results Complete (type 1) MH closure was achieved in all eyes (100%) without intraoperative flap displacement or subretinal PFCL migration. The mean BCVA improved from 0.81 ± 0.34 logMAR preoperatively to 0.41 ± 0.19 logMAR at final follow-up (mean gain 0.40 logMAR). Postoperative OCT confirmed stable ILM graft positioning without secondary contraction or migration. Conclusions By separating flap mobility from fixation in a staged manner, PFCL application may resolve the mechanical dilemma underlying ILM transplantation. Prospective pilot results supported the feasibility of the technique and showed consistent anatomical closure in refractory MHs.