RU2791656C1 - Method for surgical treatment of primary penetrating macular retinal rupture with preservation of the inner limiting membrane in the projection of the papillomacular bundle of nerve fibers - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to ophthalmology. Vitrectomy is performed, the ILM section is removed, the point of visual fixation is preserved. After vitrectomy and staining of the ILM in the area of the retina between the superior temporal and inferior temporal vascular arcades at a distance of one diameter of the optic disc from the edge of the MP concentrically to the macular hole, the ILM is removed in successive rounded fragments so as to remain intact: the band of the ILM along the border of the macular hole with a width of 0.5 mm. Inverted ILM flap with a width corresponding to the diameter of the macular hole in combination with the width of the concentric rim of the ILM that encircles it, and a length of at least one diameter of the optic disc, but not reaching the superior temporal arcade, located perpendicular to the line connecting the centers of the macular hole and the optic disc, in the direction of the superior temporal arcade. ELM flap in the area of the papillomacular bundle (PB) of the nerve fibers of the ON between the macular hole and the optic disc, the upper border of which runs along a tangent connecting the edge of the ONH and the edge of the belt of the ILM along the border of the macular hole, from the side of the superior temporal vascular arcade, and the lower border of which runs along a tangent, connecting the edge of the ONH and the edge of the ILM belt along the border of the macular hole, from the side of the inferior temporal vascular arcade. After removal of the ILM, the inverted ILM flap is separated from the retina, keeping its attachment along the edge of the ILM band around the macular hole, it is turned over and the macular hole is covered with it, plugging it. Then the liquid is replaced with an air mixture, while the liquid is removed from the side of the free edge of the inverted ILM flap.

EFFECT: method allows minimizing the risk of intraoperative trauma to the zone of the papillomacular bundle of retinal nerve fibers with the surgeon's instruments and remote pathological changes in this zone, maintaining visual fixation points along the edge of the tear, closing the macular hole with restoring the normal anatomy of the retina at the site of the macular hole, no need to use long-term absorbable gases , no need to position the patient face down, high functional result of surgical treatment, no recurrence of the disease in the long term.

1 cl, 1 ex

Description

SUBSTANCE: invention relates to medicine, namely to ophthalmology, and can be used for surgical treatment of primary penetrating macular retinal tears of any diameter.

According to the literature, surgery for macular holes (MP) with removal of the internal limiting membrane (ILM) can cause dissociation of retinal nerve fibers, foveal dystopia with displacement towards the optic nerve head (OND), narrowing of the papillofoveolar distance, thinning and stretching of the retinal tissue, as well as the appearance of paracentral microscotomas in the field of view [Bayborodov Ya.V. Anatomical and functional results of the use of various options for the technique of surgical closure of macular holes // Modern technologies in ophthalmology. - 2015. - V.5. - No. 1 - S. 22-24. Casini G., Mura M., Figus M., Loiudice P., Peiretti E., De Cilia S., Fuentes T., Nasini F. Inverted internal limiting membrane flap technique for macular holesurgery without extra manipulation of the flap // Retina . - 2017. - Vol. 37. - No 11. Bonnabel A., Bron A.M., Isaico R., et al. Long-term anatomical and functional outcomes of idiopathic macular hole surgery: the yield of spectral-domain OCT combined with microperimetry // Graefes Archive for Clinical and Experimental Ophthalmology. - 2013. - Vol. 25. - No. 11. - P. 2505-2511].

According to some authors, macularorhexis can lead to ONH atrophy in 47% of cases [Ando F., Yasui O., Hirose N., Ohba N. Optic nerve atrophy after vitrectomy with indocyanine green-assisted internal limiting membrane peeling in diffuse diabetic macular edema . Adverse effect of ICG-assisted ILM peeling // Graefes Arch. Clin. Exp. Ophthalmol. - 2004, Dec. - Vol. 242. - P. 995-999].

Despite the importance of the entire macular area of the retina, to ensure high visual acuity and ophthalmoergonomic functions, the most significant are the foveolar area of the retina and the area of the papillomacular bundle (PBC) of the nerve fibers of the optic nerve (ON) [Anatomy and physiology of the organ of vision: A textbook for students of medical universities / Comp. HELL. Chuprov, Yu.V. Kudryavtseva - under the total. ed. HELL. Chuprov - Kirov: KSMA. - 2007. - 81-88 p.].

In recent years, various surgical techniques have been proposed for the treatment of penetrating retinal MPs, aimed at reducing the invasiveness of the operation and improving the functional results of treatment.

A known method of surgical treatment of macular rupture [RF patent for invention No. 2389455], including preoperative determination of the point of visual fixation using a microperimeter, conducting virectomy, removal of the posterior hyaloid membrane (PGM), application of a perfluoroorganic compound (PFOS) to the area with a point of visual fixation, removal stained inner limiting membrane (ILM) concentrically MP, except for the area with a point of visual fixation, drainage of subretinal fluid, completion of the operation by tamponade of the vitreal cavity with a gas-air mixture. Significant disadvantages of this method are: traumatization of the retinal pigment epithelium and the edges of the macular hole during drainage of the subretinal fluid, damage to the area of the papillomacular bundle of nerve fibers as a result of the removal of the ILM, the technical difficulty of removing the ILM so as not to affect the area with the point of visual fixation, the risk of spontaneous separation of the ILM fragment in this area. All of the above reduces the likelihood of a high functional outcome of treatment.

A known method of surgical treatment of MP [RF Patent for invention No. 2409332]. In this method, depending on the diameter of the macular hole, the diameter of the ILM peeling zone around the macular hole was changed. It was recommended that the nasal margin of the maculorhexis not be brought closer to the optic nerve head (OND) by more than 1500 µm, and that the main part of the ILM should be removed from the temporal side of the macula. According to the authors, when the nasal margin of maculorhexis is located at a distance of 1500 μm from the optic disc, the damage to nerve fibers is minimal and does not cause the appearance of scotomas in the visual field. Despite the declared effectiveness of the treatment method, during the operation, damage to the edges of the rupture in the area of complete maculorhexis occurs, the point of visual fixation is damaged, and traumatization of the papillomacular bundle of nerve fibers of the optic nerve in the ILM peeling area from the nasal side of the macular zone is not excluded.

A known method of surgical treatment of MP using the technique of "inverted flap" ILM [RF patent for invention No. 2395255; Michalewska Z., Michalewski J., Adelman R., Nawrocki J. Inverted internal limiting membrane flap technique for large macular holes // Ophthalmology. - 2010. - V. 117, No 10. - P. 2018-2025]. In the named method, the ILM was removed 360 degrees concentrically to the MP, but the attachment of the ILM was retained along the edge of the macular hole. The operation was completed with gas-air tamponade. The disadvantage of this method is the inevitable excessive iatrogenic impact on the foveolar zone of the ILM along the edge of the gap and the zone of the PMP of nerve fibers, which reduces the functional result of treatment.

A known method of surgical treatment of MP using the technique of a single-layer "inverted flap" ILM [Shin M., Park K., Park S., Byon I., Lee J. Perfluoro-n-octane-assisted single-layered inverted internal limiting membrane flap technique for macular hole surgery // Retina. - 2014 Sep. - Vol. 34, No 9. - P. 1905-1910]. The ILM section was removed, retreating at a distance equal to one OD diameter from the upper edge of the macular hole, then the nasal and temporal parts of the ILM were removed from top to bottom, a single-layer ILM flap was formed, which covered the macular hole. Significant disadvantages of this method are the inevitable traumatic effect on the edges of the MP in the process of peeling the ILM and damage to the point of visual fixation along the edge of the gap.

A known method of surgical treatment of macular hole [Michalewska Z., Michalewska J., Dulczewska-Cichecka K., Adelman R.A., Nawrocki J. Temporal inverted internal limiting membrane flap technique versus classic inverted internal limiting membrane flap technique: a comparative study // Retina. - 2015 Oct. - Vol. 35. - N9. - P. 1844-1850] using the technique of "temporal inverted flap" of the ILM. In line with the method, after a standard three-port 25G vitrectomy, a section of the ILM was separated from the temporal side of the macular region, the resulting single-layer flap was turned over and placed on the macular hole, blocking it. The operation was completed with gas-air tamponade of the vitreal cavity. This technique significantly reduced the duration of the operation and minimized the area of ILM peeling, thereby reducing the risk of iatrogenic damage to the nerve fiber layer of the optic nerve, including the area of the papillomacular bundle of nerve fibers. A significant disadvantage of this method is the preservation of a large area of the intact zone of the retinal ILM, a high risk of non-closure or recurrence of a through MP, associated with the presence of tangential tractions at the edges of the tear and the basis for the development of epiretinal membranes, especially with large diameter tears (more than 400 μm), which are more difficult to treat .

A known method of surgical treatment of macular rupture [RF patent for the invention No. 2754513]. After a standard three-port 25G vitretomy, the ILM around the macular hole was removed with two large oblong fragments so as to preserve the intact retinal zone around the MP with a width of 0.5-1.0 mm. The operation was completed with gas-air tamponade. This technique is applicable in the treatment of penetrating macular holes of small and medium diameter. The disadvantage of this method is the technical complexity of intraoperatively carving out and removing two fragments of a given shape and size without using the foveal zone of the ILM of the retina. The ILM is quite elastic and prone to tearing, and the jaws of modern ILM peeling forceps are quite sharp (important for tearing the adjacent intact ILM), which forces the surgeon to remove the ILM in local small fragments. In addition, given the shape of the fundus surface (hemisphere), it is difficult to remove ILM areas of large linear extent. This question arises most acutely during manipulations from the nasal side of the MP (in the projection of the PMP). The removed ILM often breaks off in the projection of the PMP zone, which entails a new capture of the ILM in this region of the retina that is prognostically important in terms of functionality and, therefore, an unjustified risk of intraoperative iatrogenic damage to the retina and papillomucular bundle of nerve fibers of the ON. Removal of the ILM in the area of the PMP can lead to irreversible destructive changes in this area in the late postoperative period. In addition, at the final stage of ILM removal, in order to preserve the “ring” of the intact ILM around the rupture, it will inevitably be necessary to cut off the remnants of the removed ILM with a vitreotomy, which is due to the peculiarity of its physical properties and the degree of adhesion with the underlying layers of the retina. This increases the risk of tearing off the retinal remnants of the ILM from the underlying retina, which must be kept intact.

A known method of surgical treatment of macular rupture [RF patent for the invention No. 2722987]. After a standard 250-degree vitrectomy from the temporal side at a distance of 2 OD diameters from the macular hole, a vertical incision of the ILM is performed and the ILM section is separated from the retina, not reaching the edge of the MP by 1 OD diameter (about 1.5 mm) in order to maintain the point of visual fixation. The resulting fragment of the ILM is inverted and the macular hole is blocked by it. The operation is completed by tamponade of the vitreal cavity with air. This method minimizes the traumatic effect on the central retina and the papillomacular bundle (PBF) zone of the ON nerve fibers, however, tangential tractions around the macular hole remain 360 degrees, which can cause non-closure of the MP or lead to a relapse of the disease in the long-term period, because The ILM can be a substrate for the development of epiretinal membrane structures capable of constriction and increased tangential tension on the edges of the macular hole. This method is chosen for the prototype.

Based on the state of the art, the urgent task is to find a compromise between achieving a guaranteed anatomical result by maximally eliminating tangential tractions around the MP by peeling the ILM, which has an elasticity coefficient significantly higher than that of the underlying layers of the retina, and minimizing damage to the microstructures of the retina and ON, providing a high functional treatment outcome.

The objective of the invention is to create a new method of surgical treatment of primary end-to-end retinal MPs of any diameter, allowing the most delicate treatment of the structures of the patient's fundus and at the same time achieving a high anatomical and functional result of treatment.

The technical result of the proposed method is to minimize the risk of intraoperative trauma to the area of the papillomacular bundle of retinal nerve fibers with the surgeon's instruments and distant pathological changes in this area, maintaining the point of visual fixation along the edge of the gap, closing the macular hole with restoring the normal anatomy of the retina at the site of the macular gap, no need to use it for a long time absorbable gases, no need to position the patient face down, high functional result of surgical treatment, no recurrence of the disease in the long-term period.

The technical result is achieved by the fact that in the method of surgical treatment of primary penetrating macular retinal rupture with preservation of the inner limiting membrane in the projection of the papillomacular bundle of nerve fibers, including vitrectomy, removal of the ILM area, preservation of the point of visual fixation, according to the invention, after vitrectomy and staining of the ILM in the area retinas between the upper temporal and lower temporal vascular arcades at a distance of one diameter of the optic disc from the edge of the MP concentrically to the macular hole, the ILM is removed in successive rounded fragments so that they remain intact: the belt of the ILM along the border of the macular hole with a width of 0.5 mm; an inverted ILM flap with a width corresponding to the diameter of the macular hole in combination with the width of the concentric rim of the ILM that encircles it, and a length of at least one diameter of the optic disc, but not reaching the superior temporal arcade, located perpendicular to the line connecting the centers of the macular hole and the optic disc, in the direction of the superior temporal arcade ; ILM flap in the area of the papillomacular bundle (PVB) of the nerve fibers of the ON between the macular hole and the optic disc, the upper border of which runs along a tangent connecting the edge of the ONH and the edge of the belt of the ILM along the border of the macular hole, from the side of the superior temporal vascular arcade, and the lower border of which runs along a tangent , connecting the edge of the ONH and the edge of the ILM band along the border of the macular hole, from the side of the inferior temporal vascular arcade, after removing the ILM, the inverted ILM flap is separated from the retina, keeping its attachment along the edge of the ILM band around the macular hole, it is turned over and covered with it by the macular hole, plugging it ; then the liquid is replaced with an air mixture, while the liquid is removed from the side of the free edge of the inverted ILM flap.

The technical result is achieved due to the fact that:

1) preservation of an intact SLM flap in the area of the PMF of nerve fibers of the ON eliminates the risks of its damage and minimizes degenerative changes in the PMF of nerve fibers in the late postoperative period;

2) the absence of manipulations in the PMF zone of nerve fibers at the time of surgical intervention minimizes the likelihood of damage to this part of the retina, which is of particular importance in providing central vision and ophthalmoergonomic functions;

3) a decrease in the area of the removed SLM due to the preservation of its intact areas helps to reduce the duration of the operation;

4) preservation of the intact ILM belt along the border of the macular hole with a width of 0.5 mm eliminates damage to the edge of the MP and preserves the point of visual fixation;

5) removal of the ILM by rounded fragments concentric to the macular hole, with the exception of intact areas of the ILM, provides a high anatomical result in the treatment of primary through MPs of any diameter due to the elimination of tangential tractions;

6) the elimination of tangential tractions in the postoperative period contributes to the closing of the edges of the MP "butt-to-butt" and provides a shift in the point of visual fixation to the center of the fovea, which improves the functional result, speeds up the rehabilitation process and increases patient satisfaction with the treatment;

7) localization of the inverted ILM flap from above relative to the MP, from the side of the superotemporal vascular arcade, and a sufficient size of the flap, with a width corresponding to the diameter of the macular hole in conjunction with the ILM girdle surrounding it, and a length of at least one diameter of the optic disc, but not reaching the superotemporal arcade , ensures its stable position on the surface of the retina in the postoperative period and reliable prolonged tamponade of the macular hole without the need to position the patient face down;

8) refusal to use PFOS intraoperatively reduces the number of instrument manipulations in the macular area of the retina, thereby reducing the risks of intraoperative complications, reducing the operation time and eliminating the possibility of incomplete removal of PFOS bubbles from the retinal surface at the final stage of surgery;

9) due to the removal of a large percentage of the ILM around the MP, the risks of recurrence of the macular hole due to the development of epiretinal membranes on the surface of the ILM, which can serve as a substrate for their formation, are minimized.

The method is carried out as follows.

A standard transconjunctival three-port 27G vitrectomy is performed. To avoid direct exposure to a directed flow of fluid or air into the fovea, the BSS cannula into the vitreal cavity is placed at an angle of 45 degrees to the surface of the eyeball. The posterior hyaloid membrane (PHM) and the posterior cortical layers of the vitreous body are exfoliated from the optic disc and retina by aspiration. Vacuum from 0 to 650 mmHg Frequency 5000-10000 cuts/min. Stained with MembranBlue dye.

In the area of the retina between the upper temporal and lower temporal vascular arcades, at a distance of one diameter of the optic nerve head from the edge of the MP, concentric to the macular hole, the ILM is removed with successive rounded fragments. Surgical practice shows that the best way to remove the ILM according to the proposed method is the formation of five rounded fragments with movements directed along the circumference, the so-called "petal" technique. The ILM is removed so that the following remain intact: 1) the ILM belt along the border of the macular hole, 0.5 mm wide; 2) an inverted ILM flap with a width corresponding to the diameter of the macular hole in combination with the width of the concentric rim of the ILM that encircles it, and a length of at least one diameter of the optic disc, but not reaching the superior temporal arcade, located perpendicular to the line connecting the centers of the macular hole and the optic disc, in the direction superior temporal arcade; 3) the ILM flap in the area of the papillomacular bundle (PBC) of the nerve fibers of the ON between the macular hole and the optic disc, the upper border of which runs along a tangent connecting the edge of the ONH and the edge of the belt of the ILM along the border of the macular hole, from the side of the superior temporal vascular arcade, and the lower border of which passes along the tangent connecting the edge of the ONH and the edge of the ILM band along the border of the macular hole, from the side of the inferior temporal vascular arcade. After removal of the ILM, the inverted ILM flap is separated from the retina, keeping its attachment along the edge of the ILM band around the border of the macular hole. The free edge of the inverted ILM flap is turned over and the macular hole is covered with it, plugging it. Then the liquid is replaced with an air mixture, while the liquid is removed from the side of the free edge of the inverted ILM flap.

Liquid aspiration is performed using a vitreotome with a high frequency of cuts (7000-10000) in order to avoid sharp aspiration traction effects on the inverted ILM flap when the vitreous body fibers flowing down the surface of the retina and the inverted ILM flap from the periphery to the center enter the vitreotome. Vacuum - from 0 to 650 mmHg The position of the infusion cannula at an angle of 45 degrees to the surface of the eyeball parallel to the limbus minimizes the direct effect of the air flow on the central zone of the retina and the dislocation of the ILM flap. It is necessary to remove fluid from the side of the free edge of the inverted ILM flap (from the side of the inferior temporal vascular arcade). This ensures the correct direction of the fluid flow through the retina in the "air" medium in the direction from the superior temporal to the inferior temporal vascular arcade (top to bottom), in order to prevent the flap from turning in the opposite direction (towards the superior temporal vascular arcade) and ensure the correct position inverted ILM flap on the retinal surface without the use of PFOS, thereby reliably plugging the MP.

The described techniques create the conditions for the fastest and safest drying of the macula and the inverted ILM flap, eliminating the risks of dislocation, deployment of the flap or its detachment from the retina through fluid flow from top to bottom along the surface of the macular interface. At the final stage, it is important to assess the correct position of the inverted ILM flap, which is clearly visible on the dried macular area of the retina and has a characteristic luster that facilitates its differentiation on the retinal surface.

The operation is completed with the removal of the ports, the sclerotomies are sealed independently, without sutures.

The invention is illustrated by the following clinical data.

Clinical example. Patient Sh., 46 years old. Diagnosis: OS - primary penetrating macular hole of the retina of large diameter. Complaints about the distortion of lines and objects, low vision near and far.

Upon admission to the clinic, visual acuity with a correction of 0.1 is eccentric. According to microperimetry, the central photosensitivity is 18.6 dB. Visual fixation is stable. The point of visual fixation is located along the upper temporal edge of the MP at a distance of 193 µm from the edge.

According to spectral optical coherence tomography (SOCT): the minimum rupture diameter is 617 µm, the maximum diameter is 974 µm, the height of the rupture is 444 µm, and the average thickness of the retina in the fovea is 381 µm.

The patient underwent surgical treatment using the proposed method while maintaining the internal limiting membrane in the projection of the papillomacular bundle of nerve fibers.

A standard transconjunctival three-port 27G vitrectomy was performed. To avoid direct exposure to a directed flow of fluid or air into the fovea, the cannula for delivering BSS into the vitreal cavity was placed at an angle of 45 degrees to the surface of the eyeball. The posterior hyaloid membrane (PHM) and the posterior cortical layers of the vitreous body were exfoliated from the optic disc and retina by aspiration. Vacuum from 0 to 650 mmHg Frequency 5000-10000 cuts/min. IPM was stained with MembraneBlue dye.

In the area of the retina between the superior temporal and inferior temporal vascular arcades, at a distance of one optic disc diameter from the edge of the MP, concentric to the macular hole, the ILM was removed with five successive rounded fragments using the "petal" technique. The ILM was removed so that the following remained intact: 1) the ILM belt along the border of the macular hole, 0.5 mm wide; 2) an inverted ILM flap with a width corresponding to the diameter of the macular hole in combination with the width of the concentric rim of the ILM that encircles it, and a length of at least one diameter of the optic disc, but not reaching the superior temporal arcade, located perpendicular to the line connecting the centers of the macular hole and the optic disc, in the direction superior temporal arcade; 3) the ILM flap in the area of the papillomacular bundle (PBC) of the nerve fibers of the ON between the macular hole and the optic disc, the upper border of which runs along a tangent connecting the edge of the ONH and the edge of the belt of the ILM along the border of the macular hole, from the side of the superior temporal vascular arcade, and the lower border of which passes along the tangent connecting the edge of the ONH and the edge of the ILM band along the border of the macular hole, from the side of the inferior temporal vascular arcade. After removal of the ILM, the inverted ILM flap was separated from the retina, keeping its attachment along the edge of the ILM band around the border of the macular hole. The free edge of the inverted ILM flap was turned over and covered the macular hole with it, plugging it. Then the liquid was replaced with an air mixture, while the liquid was removed from the side of the free edge of the inverted ILM flap.

Fluid aspiration was performed using a vitreotome with a high frequency of cuts (7000-10000) to avoid sharp aspiration traction effects on the inverted ILM flap when the vitreous body fibers flowing down the surface of the retina and the inverted ILM flap from the periphery to the center entered the vitreotome. Vacuum - from 0 to 650 mmHg The position of the infusion cannula at an angle of 45 degrees to the surface of the eyeball parallel to the limbus made it possible to minimize the direct effect of the air flow on the central zone of the retina and the dislocation of the ILM flap. PFOS, non-resorbable gases were not used. At the final stage, the inverted ILM flap was clearly visible, it had a characteristic luster, and completely plugged the macular hole. The sclerotomy was not sutured.

There were no intraoperative complications.

After the operation, the patient was in a free position, without positioning face down.

Positive dynamics was observed 2 weeks after the operation. According to SOCT, the closure of the macular hole was recorded with the preservation of the defect at the level of the ellipsoidal zone of photoreceptors with a length of 196 μm. The maximum correctable visual acuity (BCVA) increased to 0.3. Central photosensitivity increased to 22.5 dB, according to microperimetry. Visual fixation is stable.

After 1 month, according to SOCT, MP is closed, the defect in the ellipsoidal zone of photoreceptors has decreased to 78 microns. BCVA-0.6. An increase in central photosensitivity up to 23.4 dB was noted, according to microperimetry. Visual fixation is stable.

After 3 months, according to SOCT, MP is closed, the defect in the ellipsoidal zone of photoreceptors has decreased to 40 μm. BCVA-0.6. Central photosensitivity - 26.3 dB, according to microperimetry. Visual fixation is stable.

After 6 months, according to SOCT data, the MP was closed joint-to-butt, the normal anatomy of the retina at the site of the macular rupture was restored. BCVA-0.7. Central photosensitivity - 26.3 dB, according to microperimetry. Visual fixation is stable. There were no complications or recurrences during the observation period.

Thus, the claimed method ensures minimization of the risk of intraoperative trauma to the zone of the papillomacular bundle of retinal nerve fibers with the surgeon's instruments and distant pathological changes in this zone, maintaining the point of visual fixation along the edge of the tear, closing the macular hole with restoring the normal anatomy of the retina at the site of the macular hole, no need to use long-term absorbable gases, no need to position the patient face down, high functional result of surgical treatment, no recurrence of the disease in the long-term period.

Claims (1)

A method for surgical treatment of primary penetrating macular retinal rupture with preservation of the internal limiting membrane in the projection of the papillomacular bundle of nerve fibers, including vitrectomy, removal of the ILM area, preservation of the point of visual fixation, characterized in that after vitrectomy and staining of the ILM in the retinal zone between the superior temporal and inferior temporal vascular arcades at a distance of one diameter of the optic nerve head from the edge of the MP concentric to the macular hole remove the ILM in successive rounded fragments so that they remain intact: the band of the ILM along the border of the macular hole with a width of 0.5 mm; an inverted ILM flap with a width corresponding to the diameter of the macular hole in combination with the width of the concentric rim of the ILM that encircles it, and a length of at least one diameter of the optic disc, but not reaching the superior temporal arcade, located perpendicular to the line connecting the centers of the macular hole and the optic disc, in the direction of the superior temporal arcade ; ILM flap in the area of the papillomacular bundle (PVB) of the nerve fibers of the ON between the macular hole and the optic disc, the upper border of which runs along a tangent connecting the edge of the ONH and the edge of the belt of the ILM along the border of the macular hole, from the side of the superior temporal vascular arcade, and the lower border of which runs along a tangent , connecting the edge of the ONH and the edge of the ILM band along the border of the macular hole, from the side of the inferior temporal vascular arcade, after removing the ILM, the inverted ILM flap is separated from the retina, keeping its attachment along the edge of the ILM band around the macular hole, it is turned over and covered with it by the macular hole, plugging it ; then the liquid is replaced with an air mixture, while the liquid is removed from the side of the free edge of the inverted ILM flap.