Multi-Flap Free Internal Limiting Membrane Grafting with Sub-Perfluorocarbon Liquid Stabilization: A Hybrid Technique for Refractory Macular Holes.

PURPOSE: To describe a hybrid surgical sequence using multi-flap free internal limiting membrane (ILM) grafting with sub-perfluoro-n-octane (PFO) stabilization for repair of a persistent large macular hole (MH) after prior ILM peeling. METHODS: A 70-year-old pseudophakic woman presented with a persistent large full-thickness MH in the right eye two months after pars plana vitrectomy with ILM peel and sulfur hexafluoride (SF6) tamponade (BCVA 20/200). Revision surgery was performed with ILM staining using indocyanine green, followed by the creation of three small, hinged ILM flaps from the edge of the prior peel border in balanced salt solution. PFO was then injected over the entire posterior pole. Under the PFO bubble, the hinged flaps were converted to multiple free ILM graft fragments, transferred sub-PFO, and layered within the MH crater to augment scaffold volume. Fluid-air exchange was completed followed by 15% perfluoropropane (C3F8) gas tamponade with intraoperative confirmation of graft retention. Postoperative positioning included upright positioning during the day and side sleeping at night. RESULTS: Intraoperative visualization demonstrated stable retention of the ILM graft fragments within the MH after fluid-air exchange. At postoperative month 5, optical coherence tomography confirmed complete MH closure, and BCVA improved from 20/200 to 20/50 in the operative eye. CONCLUSION: Multi-flap free ILM grafting performed with sub-PFO transfer and stabilization offers enhanced fluidics control and mechanical graft retention during fluid-air exchange, providing a practical technique for refractory MH repair when juxtafoveal ILM is exhausted after prior peeling.