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For the surgical treatment of idiopathic thickness macular hole, the question of whether to peel or not to peel the internal limiting membrane (ILM) has been asked repeatedly since at least 2002.12 Most surgeons carry out ILM peeling routinely. Many are already convinced of its benefit. Is it worthwhile conducting a randomised trial when the clinical practice of ILM peel has already been widely adopted? Is the answer simply academic?
If all macular holes respond in the same way to surgery, the answer might indeed be academic. They do not. It is now clear that smaller holes close more readily.3 A lesser intervention may be appropriate for the treatment of smaller holes. For example, a recent randomised trial comparing a facedown versus a seated position found that the success rate in idiopathic macular holes smaller than 400 µm was not influenced by postoperative posture.4
On the other hand, if the maximum intervention works best, why not apply it to every patient? After all, there is a price to pay for failure in primary closure. Holes that do not close after the first vitrectomy tend to increase in size, and even when they are closed with a repeat operation, the visual results are often poor.5 The …