Abstract
<title>Abstract</title> <p>Background Internal limiting membrane (ILM) peeling improves anatomical closure in idiopathic macular hole surgery but may injure the inner retina through the anteroposterior traction of conventional forceps peeling. We describe a technique of circumferential ILM demarcation with a flexible nitinol loop, which engages the ILM through tangential forces, performed before inverted ILM flap creation, and report its preliminary anatomical and functional outcomes. Methods This retrospective interventional case series included consecutive eyes with idiopathic macular hole that underwent 25-gauge pars plana vitrectomy with circumferential ILM demarcation and an inverted ILM flap by a single surgeon. After indocyanine green staining, the Finesse Flex Loop (Alcon, Fort Worth, TX, USA) was used to perform nearly 360-degree tangential scoring of the intended peel boundary approximately 1 disc diameter from the fovea before flap elevation. Best-corrected visual acuity (BCVA), anatomical closure, closure morphology, and inner retinal surface irregularity were assessed on spectral-domain optical coherence tomography at 3 months postoperatively. Results Ten eyes of 9 patients (mean age 64.8 ± 5.1 years) were included. The mean minimum linear diameter was 363.5 ± 176.8 µm and the mean base diameter was 763.7 ± 248.1 µm. Anatomical closure was achieved in all 10 eyes (100%), with a U-shaped configuration in 8 eyes (80%) and a V-shaped configuration in 2 eyes (20%). Mean BCVA improved from 0.58 ± 0.39 to 0.20 ± 0.17 logMAR at 3 months (p = 0.002), with improvement observed in all eyes. Inner retinal surface irregularity consistent with retinal dimpling was noted in 6 eyes (60%). No intraoperative or postoperative complications occurred. Conclusions Circumferential ILM demarcation with a flexible loop is a feasible technique that provides precise control of the peel margin and achieved 100% anatomical closure with significant visual improvement in this preliminary series. Comparative studies with larger cohorts and longer follow-up are warranted to confirm these preliminary results and its potential advantages over conventional forceps peeling.</p>