486 Journal of the College of Physicians and Surgeons Pakistan 2017, Vol. 27 (8): 486-489 INTRODUCTION A macular hole is a retinal break located in the macula. It usually exhibits early central visual loss, meta- morphopsia and central scotomas. Women develop macular holes more commonly than men, typically in the 5th decade. 1 Although mostly idiopathic, macular hole can develop secondary to uveitis, retinal detachment, cataract surgery, ocular trauma and photocoagulation. The diagnosis of a macular hole was traditionally made on clinical grounds. In 1988, Gass proposed a classification for idiopathic macular holes. 2 Stage 1 is a pre-macular hole; stage 2 is a full thickness macular hole (FTMH) of < 400 microns diameter; stage 3 is a FTMH of > 400 microns diameter; and stage 4 denoted a stage 3 macular hole associated with posterior vitreous detachment (PVD). Some authors have designated as stage 0 the asymptomatic eye when the contralateral eye has been diagnosed with FTMH. Optical coherence tomography (OCT) has gradually assumed an important role for diagnosing macular hole as well as for postoperative assessment of anatomical closure. Spectral domain OCT (SD-OCT) has become crucial in the preoperative diagnosis of macular hole, assessment of its dimensions, calculation of macular hole index (used in predicting the postoperative closure rates) and in postoperative follow-up to confirm the hole closure. A strictly anatomic OCT-based classification for diseases of the vitreomacular interface (VMI), 3 divided FTMH into small (< 250 microns), medium and large (> 400 microns), and included vitreomacular adhesion (VMA), vitreomacular traction (VMT) in the classification. 3 VMA is an asymptomatic elevation of the cortical vitreous above the retinal surface, with the vitreous remaining attached within a 3 mm radius of the fovea, which is equivalent to stage 0. If there are associated detectable retinal anatomic changes detected on OCT, the eye is classified as having VMT, which is stage 1 in the Gass classification. The basement membrane of Muller cells, the internal limiting membrane (ILM) has been suggested to be involved in pathogenesis of macular hole by disturbing the vitreomacular interface, causing vitreomacular traction; and subsequently, resulting in macular hole. 4 This implied that once ILM is peeled off, it will remove the traction overlying the macular area and halt the process of hole formation. ILM is a thin and transparent acellular membrane, which is 138 ± 80 nm thick at the foveal center. 5 Peeling of this almost indistinguishable ORIGINAL ARTICLE Anatomical Outcome Following Indocyanine Green Assisted Internal Limiting Membrane Peeling for Stage 3 and 4 Macular Hole Surgery Shahab Ul Hasan, Syed Fawad Rizvi, Syed Asaad Mahmood, Shakir Zafar and Tanweer Hasan ABSTRACT Objective: To evaluate the anatomical success of stage 3 and 4 macular hole surgery after removal of internal limiting membrane (ILM) with the help of Indocyanine green (ICG). Study Design: An experimental study. Place and Duration of Study: LRBT Tertiary Care Eye Hospital, Karachi, October 2015 to August 2016. Methodology: Twenty patients with stage 3 and 4 macular hole (confirmed by spectral domain optical coherence tomography) underwent standard 3 ports pars plana vitrectomy. Staining of ILM was performed with the help of 0.5% ICG to aid in visualization. ILM was removed by using intraocular forceps in circular fashion. Finally, gas fluid exchange with internal tamponade of SF6 20% was performed. Postoperative face down posture was maintained for seven days. Patients were followed-up for 8 months and assessment of macular hole closure was done using SD-OCT. Results: After a follow-up of 8 months, macular hole was closed in 17 eyes (85%) and vision had improved in 6 patients. Postoperative complications included cataract, hyphema and vitreous hemorrhage. Conclusion: Surgery for stage 3 and 4 macular hole with ILM peeling has high anatomical success rate. Final visual acuity is dependent on preoperative macular hole stage and visual acuity at presentation. Key Words: Epiretinal membrane. Macular hole. Optical coherence tomography. Vitrectomy. Indocyanine green. Department of Ophthalmology, LRBT Free Base Eye Hospital, Karachi. Correspondence: Dr. Syed Asaad Mahmood, Department of Ophthalmology, LRBT Free Base Eye Hospital, Korangi 2 1 / 2, Karachi-74900. E-mail: syed_asaad@yahoo.com Received: January 21, 2017; Accepted: August 29, 2017.