From Peel to Plug: Sealing The Gap With Surgical Innovations For Macular Hole Repair

The surgical management of macular holes (MH) has evolved significantly over the past few decades. In 1991, Kelly and Wendel revolutionized MH repair by introducing pars plana vitrectomy combined with air fluid exchange. Eckardt et al. in 1997 further advanced and improved the success of macular hole closure by introducing internal limiting membrane (ILM) peeling, establishing the gold standard for idiopathic MH treatment. The subsequent development of micro-incision vitrectomy systems, particularly 25- and 27-gauge instrumentation, has resulted in better wound sealing, reduced postoperative inflammation, and faster visual recovery. These technological advancements laid the foundation for more complex surgical approaches, especially in complex cases such as large, recurrent, persistent, traumatic or myopic MHs. Contemporary techniques now include a variety of ILM flap methods (e.g., inverted, temporal, single-layer, and multilayered/petal flaps), autologous ILM transplantation (AILMT), human amniotic membrane (hAM) grafts, and autologous retinal transplantation (ART).