Vitrectomy in Small idiopathic MAcuLar hoLe (SMALL) study: Internal limiting membrane peeling versus no peeling

Abstract Purpose To compare vitrectomy with and without internal limiting membrane (ILM) peeling in small idiopathic macular holes. Methods Retrospective multicentre study including consecutive eyes with ≤250 μm idiopathic macular hole treated with vitrectomy. The primary outcome was hole closure rate. Best‐corrected visual acuity (BCVA) change, closure patterns on optical coherence tomography, rates of external limiting membrane (ELM) and ellipsoid zone (EZ) recovery, and rate of complications were also investigated. Results In total, 693 eyes were included. Hole closure rate was 98% in the peeling and 85% in the no‐peeling group ( p < 0.001). At 12 months, mean BCVA change was 0.38 ± 0.22 logMAR in the peeling and 0.45 ± 0.21 logMAR in the no‐peeling group ( p = 0.02); 66% versus 80% of eyes had a U‐shaped morphology, respectively; EZ recovery rate was 75% and 93%, respectively ( p = 0.02). In the no‐peeling group, eyes with a vitreomacular traction (VMT) showed a 96% closure rate, comparable to the peeling group ( p = 0.40). The incidence of adverse events was similar except for dissociated optic nerve fibre layer (55% in the peeling vs. 9% in the no‐peeling group, p < 0.001). Conclusions In small idiopathic macular holes, ILM peeling provides a higher closure rate compared to no‐peeling; however, if a VMT is present closure rates are comparable. In closed macular holes, the no‐peeling technique provides advantages in terms of visual outcome and anatomical recovery.