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To the Editor:
We thank Baskaran et al for their precious contribution and for the interest they have shown in our article.1
In Group 2, we performed a circumferential peeling, and a funnel of internal limiting membrane was left attached to the edges of the macular hole. During fluid–air exchange, the flap flattened because of air pressure. Although fluid–air interface was horizontal, fluid aspiration was performed nasally to the fovea in the papillary area. We observed that the funnel banded and flattened covering the macular hole. Air–gas exchange was done under visualization to check the flap position. Actually, the reasons of anatomical failure after macular hole surgery are not completely understood. Multiple elements as poor patient compliance with postoperative posturing regimens, long macular hole duration, and advanced macular hole stage are known to be negative prognostic factors for anatomical success.2 In our case, anatomical closure was not reached in 2 patients who had long duration holes (20 months for Group 1 and 24 months for Group 2), with a minimum and maximum diameter of 572 μm and 1,089 μm for Group 1 and 621 μm and 1,165 μm for Group 2. Inverted internal limiting membrane technique led to an improvement of the rate of anatomical closure offering a scaffold for cell migration.3 Further studies may be required to better understand why certain cases fail to close after the first surgical attempt.
We did not observe any dislodgment of the flap. In our opinion, this may be due to the technique described on the paper. In fact, whichever was the direction taken by the internal limiting membrane funnel (either temporal, nasal, upper, or lower), the holes resulted covered by an inverted internal limiting membrane flap.
Finally, Baskaran suggested comparing the retinal pigmented epithelium changes between groups using fundus autofluorescence imaging. It may be an interesting and valid inspiration for future studies.
We hope we have exhaustively replied to our colleagues.
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