Staged PFCL-assisted ILM free flap transplantation for refractory macular holes: resolving the mechanical paradox of graft instability
4 affiliations
- 1Department of Ophthalmology, Niigata City General Hospital, 463-7 shumoku, Chu-o-ku, Niigata City, Niigata 950-1197 Japan
- 2Department of Ophthalmology, Niigata University Graduate School of Medical and Dental Science, Niigata, Japan
- 3Takasaki Sato Eye Clinic, Minamiorui, Takasaki, Gunma Japan
- 4Subarukai Eye Center, Higashi-Ohmi City, Shiga Japan
Abstract
Introduction: Primary pars plana vitrectomy with internal limiting membrane (ILM) peeling closes over 90% of idiopathic full-thickness macular holes (MHs), and revision surgery is challenging owing to limited remaining ILM, especially in myopic or extensively peeled eyes. The present study aimed to propose a staged perfluorocarbon liquid (PFCL)-assisted dual-interface stabilization strategy for autologous ILM free flap transplantation in refractory MHs and provide its biomechanical rationale along with prospective pilot clinical validation.
Methods: This prospective, multi-center interventional case series included five consecutive eyes with refractory full-thickness MHs (mean age 68.3 ± 8.8 years; mean minimum linear diameter 449.2 ± 196.5 μm) following prior pars plana vitrectomy with ILM peeling and gas tamponade. The framework consisted of (1) placement of an ophthalmic viscoelastic device (OVD) plug within the MH, (2) limited PFCL stabilization, (3) ILM flap preparation outside the PFCL meniscus to preserve membrane mobility, and (4) secondary PFCL expansion before fluid–air exchange. Anatomical closure and best-corrected visual acuity (BCVA) were evaluated during at least 3 months of follow-up.
Results: Complete (type 1) MH closure was achieved in all eyes (100%) without intraoperative flap displacement or subretinal PFCL migration. The mean BCVA improved from 0.81 ± 0.34 logMAR preoperatively to 0.41 ± 0.19 logMAR at final follow-up (mean gain 0.40 logMAR). Postoperative OCT confirmed stable ILM graft positioning without secondary contraction or migration.
Conclusions: By separating flap mobility from fixation in a staged manner, PFCL application may resolve the mechanical dilemma underlying ILM transplantation. Prospective pilot results supported the feasibility of the technique and showed consistent anatomical closure in refractory MHs.
Supplementary Information: The online version contains supplementary material available at https://doi.org/10.1186/s40942-026-00909-z.
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BibTeX
@article{nakano2026staged,
title = {{Staged PFCL-assisted ILM free flap transplantation for refractory macular holes: resolving the mechanical paradox of graft instability}},
author = {Hideyuki Nakano and Hiroko Terashima and Taku Sato and Kazuhito Yoneda and Jiro Kogo and Kenji Murakami},
journal = {International Journal of Retina and Vitreous},
year = {2026},
month = jul,
doi = {10.1186/s40942-026-00909-z},
url = {https://doi.org/10.1186/s40942-026-00909-z},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Staged PFCL-assisted ILM free flap transplantation for refractory macular holes: resolving the mechanical paradox of graft instability
AU - Hideyuki Nakano
AU - Hiroko Terashima
AU - Taku Sato
AU - Kazuhito Yoneda
AU - Jiro Kogo
AU - Kenji Murakami
PY - 2026
DA - 2026/07/29
JO - International Journal of Retina and Vitreous
DO - 10.1186/s40942-026-00909-z
UR - https://doi.org/10.1186/s40942-026-00909-z
AB - Introduction: Primary pars plana vitrectomy with internal limiting membrane (ILM) peeling closes over 90% of idiopathic full-thickness macular holes (MHs), and revision surgery is challenging owing to limited remaining ILM, especially in myopic or extensively peeled eyes. The present study aimed to propose a staged perfluorocarbon liquid (PFCL)-assisted dual-interface stabilization strategy for autologous ILM free flap transplantation in refractory MHs and provide its biomechanical rationale along with prospective pilot clinical validation. Methods: This prospective, multi-center interventional case series included five consecutive eyes with refractory full-thickness MHs (mean age 68.3 ± 8.8 years; mean minimum linear diameter 449.2 ± 196.5 μm) following prior pars plana vitrectomy with ILM peeling and gas tamponade. The framework consisted of (1) placement of an ophthalmic viscoelastic device (OVD) plug within the MH, (2) limited PFCL stabilization, (3) ILM flap preparation outside the PFCL meniscus to preserve membrane mobility, and (4) secondary PFCL expansion before fluid–air exchange. Anatomical closure and best-corrected visual acuity (BCVA) were evaluated during at least 3 months of follow-up. Results: Complete (type 1) MH closure was achieved in all eyes (100%) without intraoperative flap displacement or subretinal PFCL migration. The mean BCVA improved from 0.81 ± 0.34 logMAR preoperatively to 0.41 ± 0.19 logMAR at final follow-up (mean gain 0.40 logMAR). Postoperative OCT confirmed stable ILM graft positioning without secondary contraction or migration. Conclusions: By separating flap mobility from fixation in a staged manner, PFCL application may resolve the mechanical dilemma underlying ILM transplantation. Prospective pilot results supported the feasibility of the technique and showed consistent anatomical closure in refractory MHs. Supplementary Information: The online version contains supplementary material available at https://doi.org/10.1186/s40942-026-00909-z.
SN - 2056-9920
ER -