Viscoelastic-Assisted Rescue of Unintended Free Internal Limiting Membrane Flaps During Macular Hole Surgery: A Two-Case Report

Abstract

Background/Objectives: Manipulation of an internal limiting membrane (ILM) flap can be technically challenging during macular hole (MH) surgery, particularly in highly myopic eyes with fragile ILM. Although ophthalmic viscosurgical devices (OVDs) have been used to stabilize inverted ILM flaps, their use for the rescue of unintended free-floating ILM flaps has been less well described. This study aimed to describe a perfluorocarbon liquid (PFCL)-free, viscoelastic-assisted rescue technique for the capture, transfer, and stabilization of unintended free ILM flaps during MH surgery. Methods: Two highly myopic eyes with MH underwent 27-gauge pars plana vitrectomy with an ILM flap technique. When the ILM became unintentionally detached and formed a free-floating flap, a dispersive OVD was delivered through a blunt-tip cannula to capture the flap. The OVD and attached flap were manipulated as a single unit and repositioned over the MH without direct forceps grasping. An additional OVD was applied over the flap for stabilization before fluid–air exchange and 20% sulfur hexafluoride gas tamponade. Results: MH closure was confirmed via optical coherence tomography on the first postoperative day in both eyes and was maintained through the final follow-up at 5 months in Case 1 and at 1 month in Case 2. Best-corrected visual acuity was 20/33 (0.22 logMAR) at final follow-up in both eyes, compared with 20/40 (0.30 logMAR) preoperatively. No procedure-related intraoperative or postoperative complications were observed during the available follow-up periods. Conclusions: This viscoelastic-assisted technique may provide a practical rescue approach for unintended free-floating ILM flaps during MH surgery without the need for direct forceps grasping or PFCL. Larger comparative studies with longer follow-up are needed to evaluate its reproducibility, safety, and clinical utility.