Abstract
BACKGROUND: A macular hole (MH) is a retinal condition affecting the central macula, leading to progressive visual impairment. Pars plana vitrectomy with internal limiting membrane (ILM) peeling is the standard surgical treatment, while the inverted ILM flap technique has emerged as a promising alternative. However, the effectiveness of this technique was still debated. METHODS: Randomized controlled trials (RCTs) comparing ILM peeling and inverted ILM flap for MH were identified through searches in PubMed, ScienceDirect, Cochrane Library, and ClinicalTrials.gov in the last 15 years that compared ILM peeling and inverted ILM flap procedure. The primary outcome was anatomical closure, and the secondary outcome was visual acuity (VA) post-procedure. Data synthesis was performed using Review Manager (RevMan) 5.4.1 with odds ratio (OR) for anatomical closure and mean difference (MD) for VA with 95% confidence interval (CI). Statistical significance is achieved when the p-value is below 0.05. RESULTS: Twelve RCTs involving 719 patients were included. The inverted ILM flap showed superior anatomical closure (OR 0.28; 95% CI: 0.15-0.52; p < 0.0001). VA post-procedure, based on follow-up time (3-, 6-, and 12-month), revealed no statistically significant difference in visual outcomes. Sensitivity analyses confirmed anatomical and visual benefits of the inverted flap in large MHs (≥ 400 μm). CONCLUSION: The inverted ILM flap technique offers better anatomical outcomes than ILM peeling, especially for larger MHs. Visual improvement is variable and may depend on MH chronicity and retinal recovery. Further high-quality studies are needed to confirm these findings.