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To the Editor:
We congratulate Casini et al1 for their work on “Inverted internal limiting membrane flap technique for macular hole surgery without extra manipulation of the flap.” The authors have described a novel method of achieving inversion of the internal limiting membrane over the macular hole with minimal manipulation. The authors have used air to close the internal limiting membrane funnel and cover the hole. During fluid–air exchange in the primary position, we have observed that the fluid–air interface is always horizontal. This would lead to opening up of the internal limiting membrane flap funnel. So, was any globe rotation needed to avoid this? Also, how was the flap position confirmed after air–gas exchange? Was the exchange done blindly or under visualization? It is impressive to note that the closure rates are comparable in both groups of patients. One eye in each group failed to close. What was the possible reason for failure? There has been no mention about flap dislodgement in the study. In fact, Michalewska et al2 in their original description of inverted flap technique reported a 14%-flap dislodgement rate. Also, how were these failed cases managed? Was a free flap surgery done? This is one of the very few studies that mentions the changes in the ellipsoid zone with time after macular hole surgery. The authors claim that surgical manipulation to tuck the internal limiting membrane flap into the hole can damage the retinal pigment epithelium and lead to atrophy. Because no extra manipulation was done in Group 2, it would be interesting to compare the retinal pigment epithelium changes between the groups using fundus autofluorescence imaging. This can strengthen the statement that the modified technique could reduce the risks of iatrogenic damage of the retinal pigment epithelium.
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