Macular Hole Closure by Internal Limiting Membrane Flap without Gas Tamponade versus Conventional Surgery
November 2025
Macular hole (MH) repair has long leaned on intraoperative gas tamponade and strict postoperative positioning to support closure and healing. This study challenges that paradigm by comparing a conventional approach (standard ILM peel + gas) to an approach with an ILM flap without gas tamponade. In 93 consecutive eyes (51 conventional, 42 ILM flap/no-gas), the authors evaluated anatomical closure at 3 months, visual acuity over time, and OCT morphological outcomes including foveal gliosis, ELM/EZ integrity and closure pattern.
Anatomical closure rates were nearly identical: 94.1% in the conventional group versus 95.2% in the no-gas ILM flap group (P = 0.812). But where the no-gas group really distinguished itself was in earlier functional recovery: at 1 week the no-gas group had mean logMAR 0.84 versus 1.48 in the conventional group (P<0.001), and at 1 month 0.73 versus 0.87 (P = 0.048). By 3 and 6 months, visual acuities converged (0.49 vs 0.54 at 3 mo, P = 0.281; 0.47 vs 0.41 at 6 mo, P = 0.991). On OCT, the no-gas group had significantly lower foveal gliosis (4.9% vs 20.0%, P = 0.043). Other morphological measures (DONFL, ELM/EZ integrity, closure pattern) were similar between groups.
What does this mean for practice? First, it suggests that for selected primary full-thickness MHs, an ILM flap without gas may deliver equivalent anatomical success while accelerating early visual recovery and reducing gliosis – all while sparing the patient from gas-related restrictions (face-down posture, travel/altitude limitations, etc). From a patient-comfort and workflow standpoint, that is compelling. However, the retrospective design, single center nature, surgeon selection criteria and potentially fewer complex cases in the no-gas arm all temper the enthusiasm. Also, longer-term outcomes (beyond 6 months) and generalizability to large holes, highly myopic eyes, or recurrent cases remain untested.
Bottom line: An ILM flap without gas tamponade may be a viable strategy for primary MH repair in appropriately selected cases, offering faster early recovery and less gliosis without compromising closure rates. Surgeons should consider patient lifestyle, travel/altitude restrictions, and anatomical features when discussing options. A prospective randomized trial would help solidify this as a change-in-practice.
