A 58-year-old pseudophakic patient presents with a full-thickness macular hole measuring 400 microns on OCT. According to the Gass classification and current surgical standards, which intraoperative step most significantly improves the anatomical closure rate?

• A Intravitreal injection of expansile gas (C3F8) at the end of surgery
• B Removal of the posterior hyaloid alone without membrane peeling
• C Placement of a silicone oil tamponade
• D Peeling of the internal limiting membrane (ILM) around the hole ✓

Explanation

ILM peeling relieves tangential traction and significantly increases closure rates for full-thickness macular holes to over 90 percent. Removing the posterior hyaloid alone (option B) is often insufficient for closure. Gas tamponade (option A) and silicone oil (option C) are adjuncts, not the primary factor determining closure. Bailey and Love and the AAOS guidelines emphasize ILM peeling as the critical step.

Reference: Bailey and Love's Short Practice of Surgery, 28th ed.

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Written and medically reviewed by the StethoPrep medical team.