Rapid choroidal neovascularization after non-flap internal limiting membrane peeling for macular hole in a patient with AMD: a case report and literature review

Choroidal neovascularization (CNV) following macular hole (MH) surgery is a rare complication. While the exact pathogenesis remains unclear, previous reports in the literature suggest that it can occur in patients with pre-existing age-related macular degeneration (AMD) or macular drusen. In this report, we present a case that highlights the potential biomechanical triggers of this complication in an eye with AMD. We report the case of a 70-year-old female patient with AMD who presented with a full-thickness macular hole (FTMH). She underwent an uncomplicated 25-gauge pars plana vitrectomy with brilliant blue G-assisted internal limiting membrane (ILM) peeling and perfluoropropane gas tamponade. Notably, the ILM flap technique was not utilized; only standard, non-flap peeling without intraoperative complications was performed. Just 6 weeks postoperatively, the patient experienced a sudden decline in visual acuity due to the rapid development of CNV at the border of the ILM peeled-off area. Intravitreal aflibercept treatment was subsequently planned. This case suggests that, in eyes with underlying AMD, CNV may develop rapidly after standard ILM peeling even without an ILM flap technique. Biomechanical stress related to ILM removal, potentially involving macular displacement and mechanical stress on Müller cells, may be a possible contributing factor, but causality cannot be established from a single case. Physicians should maintain high vigilance for this vision-threatening complication during the early postoperative period after MH surgery.