Comparison of perfluorocarbon liquid-assisted versus conventional internal limiting membrane peeling in highly myopic macular hole retinal detachment: a retrospective study

Abstract Background Macular hole retinal detachment (MHRD) in highly myopic eyes represents a severe, vision-threatening entity within the spectrum of myopic traction maculopathy (MTM) and remains among the most surgically challenging vitreoretinal conditions, primarily owing to the characteristic pathoanatomical alterations inherent to high myopia, including excessive axial elongation, posterior staphyloma, and progressive chorioretinal thinning. Purpose The primary purpose of this study was to compare postoperative restoration of ellipsoid zone (EZ) continuity between PFCL-assisted and conventional ILM inverted flap techniques for the surgical repair of high myopic MHRD, assessed on spectral-domain optical coherence tomography (SD-OCT). Secondary objectives were to compare additional anatomical outcomes (macular hole closure rate; closure morphology [U-type, V-type, W-type]; and external limiting membrane (ELM) restoration), functional outcomes (best-corrected visual acuity (BCVA) improvement), and the incidence of postoperative complications between the two groups. Methods This single-center, retrospective, non-randomized comparative case series comprised 37 highly myopic eyes (axial length ≥ 26 mm) with full-thickness MHRD that underwent primary 25-gauge pars plana vitrectomy combined with the inverted ILM flap technique between April 2022 and October 2025. Eyes were categorized into two groups based on the surgical approach employed for ILM flap manipulation: the PFCL-assisted group ( n = 20), in which perfluorocarbon liquid was utilized to stabilize the inverted ILM flap, and the conventional group ( n = 17), in which the ILM flap was positioned under balanced salt solution infusion. All patients were followed up for a minimum of 6 months, with standardized assessments performed at 3 and 6 months postoperatively. Results Baseline characteristics were comparable between the two groups. Regarding anatomical and microstructural outcomes, EZ restoration at 6 months was better in the PFCL-assisted group (70.0% vs. 29.4%, P = .02), whereas ELM restoration demonstrated no statistical significance (35.0% vs. 11.8%, P = .14). The macular hole closure rate did not reach statistical significance (85.0% vs. 70.59%, P = .43). Regarding functional outcomes, postoperative BCVA did not differ significantly between groups at either 3 months ( P = .69) or 6 months ( P = .81). However, postoperative BCVA was significantly correlated with preoperative BCVA at both 3 months ( r = .53, P = .03) and 6 months ( r = .51, P = .04). In binary logistic regression adjusted for axial length and preoperative maximum macular hole diameter, the odds of EZ continuity at 6 months were lower in the conventional group than in the PFCL-assisted group (OR = 0.02, 95% CI: 0.001 to 0.47, P = .02), and baseline logMAR BCVA (B = -0.45; 95% CI, -0.80 to -0.09, P = .02) was an independent predictor of 6-month BCVA improvement. Conclusions In highly myopic MHRD, a higher rate of EZ continuity at 6 months was observed after PFCL-assisted ILM inverted flap surgery than after conventional surgery. However, this anatomical benefit did not translate into significantly better short-term visual outcomes. All analyses were exploratory, and these findings are hypothesis-generating and require confirmation in larger prospective studies with longer follow-up.