Before MH was recognized as curable, the internal limiting membrane (ILM) was long considered a vital structure that should remain undisturbed. Early observa­tions during epiretinal membrane (ERM) surgery noted that inadvertent ILM peel­ing could occur, raising concerns about irreversible functional damage. However, clinical experiences with Terson syndrome demonstrated that removing the ILM to evacuate sub-ILM hemorrhages signicantly improved visual outcomes without long-term complications. To solidify this evidence, electron microscopy conrmed that the membrane removed in these procedures was indeed the ILM.

In 2000, the introduction of indocyanine green (ICG) for ILM staining revolu­tionized the procedure, marking the beginning of the ‘‘staining era.’’ While subse­quent studies revealed potential retinal toxicity associated with ICG, it remains widely used due to its superior staining contrast. Conversely, research has conrmed the higher safety prole of brilliant blue G (BBG), which was approved by the U.S.FDA in late 2019 for intraocular use.

In 2010, Zosia Michalewska from Łódź, Poland, rst published a randomized controlled study in Ophthalmology on the use of inverted ILM ap coverage for treating large-diameter MH, marking the beginning of the “ILM ap technology” era in MH treatment. Beyond innovations in ILM manipulation, attempts have also been made to ll MH with amniotic membrane, lens capsule, or retinal grafts to promote hole closure.

2. Staining: Prior to staining, the macular surface must be cleared of residual vitre-

precision than ERM peeling due to the fragile nature of the ILM and the risk of underlying retinal trauma.

2. Minimizing exposure time and surface area: Vital dyes should not remain in the

Additionally, Some surgeonsdiluteICG with a 5% glucose solution (approxi­mately 278 mOsm/L) tocreatean isotonic environment that protects the retina. The increased density of the glucose solution allows the dye to settle directly onto the posterior pole, minimizing dispersion. For example, mixing 0.25% ICG with 50% hypertonic glucose in a 9:1 ratio achieves the desired 5% glucose con­centration, ensuring both isotonicity and localized delivery.

ILMis the basement membrane of the retinal Müller cell footplates, composed pri­marily of type IV collagen. Its thickness varies signicantly across the retina: approximately 400nm in the periphery, increasing to about 1,400nm in the peri­macular region. The ILM contributes nearly 50% of the structural rigidity of the retinal nerve ber layer (RNFL). Unlike pathological epiretinal membranes, the ILM is a continuous, translucent, and smooth layer without pre-existing edges or folds. While the technique resembles the continuous curvilinear capsulorhexisin cataract surgery, the clinical priority is fundamentally different: the underlying neu­rosensory retina must be strictly preserved, whereas the lens cortex is intended for removal.

The mechanics of ILM ap initiation rely on applying tensile stress to the mem­brane surface using micro-forceps. By engaging the ILM at two minute contact points and applying traction, the surgeon induces focal strain. When this stress exceeds the membrane’s tensile strength, a controlled tear occurs, allowing the ap to be initiated. Consequently, surgeons must focus on the precision and uidity of the ‘‘pinching’’ and ‘‘lifting’’ maneuvers to achieve a successful ap without trau­matizing the underlying retinal architecture.

2. Surgical eld defocus: (Instrument Myopia and Defocus): When utilizing surgi-

3. Depth Perception and Spatial Judgment: Because the ILM is a smooth, continu-