Internal Limiting Membrane Flaps in Macular Hole Surgery
Bibliographic record
Abstract
TOPIC: To compare anatomic and visual outcomes of internal limiting membrane (ILM) flaps versus peeling in macular hole surgery, considering hole size, symptom duration, and different flap types. CLINICAL RELEVANCE: The benefit of ILM flaps over standard ILM peeling in idiopathic full-thickness macular holes (iFTMHs) remains unclear. METHODS: Registered systematic review and individual participant data (IPD) meta-analysis of randomized controlled trials comparing conventional ILM peeling with ILM flaps in adults undergoing primary iFTMH surgery (CRD42023494971). No exclusions based on hole size, symptom duration, or perioperative choices. Searches in MEDLINE, Embase, Cochrane Library, and trial registries. Critical outcomes were hole closure and postoperative visual acuity at 6 months or nearest time point. Regression models adjusted for age, sex, hole size, lens status, and preoperative visual acuity, allowing for nonlinear effects. Evidence was appraised with Cochrane Risk of Bias, Grading of Recommendations Assessment, Development, and Evaluations, and the Instrument to assess the Credibility of Effect Modification in Analyses. Subgroup analyses considered hole size, symptom duration, flap subtypes, tamponade choice, and risk-of-bias. RESULTS: Thirteen trials provided IPD for 792 eyes. Most (68.3%) had minimum linear diameter ≥500 μm, with limited representation of holes <400 and ≥900 μm. The adjusted odds ratio (OR) for primary closure with ILM flap versus peeling was 4.80 (95% confidence interval, 2.77-8.30; P < 0.001), with a relative risk of 1.26 (1.20-1.30) (Grading of Recommendations Assessment, Development, and Evaluations: moderate-certainty), and a number needed to treat of 6. Compared with peeling, the ILM flap group showed better postoperative visual acuity at 3 to 6 months, with a mean difference (MD) of -0.14 logarithm of the minimum angle of resolution (-0.18 to -0.09; P < 0.001), about 7 letters ETDRS (Grading of Recommendations Assessment, Development, and Evaluations: moderate-certainty). Internal limiting membrane flaps were likely more beneficial for holes ≥500 μm (OR for closure: 3.14-9.64, P < 0.001; MD in vision: -0.23 to -0.13, P < 0.001). Nonlinear analyses suggested probable benefits across a broader range of hole sizes (Instrument to assess the Credibility of Effect Modification in Analyses: moderate-confidence). Results were consistent across risk-of-bias assessments, with no significant differences between ILM flap techniques. CONCLUSION: Internal limiting membrane flaps likely improve closure and visual recovery compared with peeling alone in iFTMH, with greater effects likely in holes >500 μm. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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How this classification was reachedexpand
Full frame distilled prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. Learned from the 10,348 direct Codex labels and 10,348 direct Gemma labels. Candidate is the union of thresholded teacher heads; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels or direct frontier model labels.
Codex and Gemma teacher scores by category
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.001 | 0.001 |
| Meta-epidemiology (narrow) | 0.001 | 0.001 |
| Meta-epidemiology (broad) | 0.005 | 0.002 |
| Bibliometrics | 0.001 | 0.001 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.000 | 0.000 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.001 | 0.001 |
| Insufficient payload (model declined to judge) | 0.001 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one teacher head, not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".