Literature Review of Treatment of Challenging Macular Holes

Full-thickness macular holes (FTMHs), particularly challenging cases such as large (>650 µm), recurrent, or myopic holes, pose significant surgical challenges. Their pathogenesis involves vitreomacular traction, with classifications (Gass, IVTS, CLOSE) guiding management. Despite standard pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling achieving >90% closure in typical cases, success rates decline in complex scenarios. This review evaluates evolving surgical techniques for challenging FTMHs, focusing on anatomical and functional outcomes of novel ILM flap modifications, adjuvant therapies, and alternative approaches. A synthesis of clinical studies, meta-analyses, and case series was conducted. Key techniques analyzed include inverted ILM flaps, perfluorocarbon liquid (PFCL)-assisted stabilization, viscoat adhesion, retracting-door flaps, and advanced methods like autologous retinal transplantation (ART), human amniotic membrane (hAM) grafts and Plasma-rich growth factor (PRGF). The inverted ILM flap technique demonstrated superior closure rates (95.6% vs. 78.6% with conventional peeling) for large holes. PFCL and viscoat further enhanced stability, achieving 100% closure in high myopia. For holes >800 µm, hAM grafts and ART showed 100% and 90.5% closure, respectively, with ART improving vision by four lines. (PRGF) membranes also facilitated closure in refractory cases. Advanced ILM flap techniques and adjunctive strategies significantly improve outcomes for challenging FTMHs. Tailored approaches based on hole size, etiology, and ocular anatomy are critical. Further research is warranted to optimize protocols for giant holes (>1000 µm) and validate emerging therapies like PRGF.