Surgical management of macular telangiectasia type 2-associated macular hole with internal limiting membrane deficiency and imaging assessment of müller cell function

This study presents a rare case of macular telangiectasia type 2 (Mac Tel 2) with a secondary full-thickness macular hole, in which an unexpected internal limiting membrane (ILM) deficiency was discovered intraoperatively. Swept-source OCT angiography (SS-OCTA) volumetric data were utilized to construct 3D models for the assessment of Müller cell function. Although ILM flap surgery achieved initial anatomical closure and visual improvement, the hole reopened after six years, with corresponding vision decline. Intraoperative ICG staining revealed patchy ILM absence, indicating severe Müller cell dysfunction. 3D vascular and structural analysis demonstrated topographic collapse correlating with loss of cytoskeletal support from Müller cells, explaining the temporary surgical success and subsequent recurrence. The findings suggest that long-term closure of Mac Tel 2-associated macular holes depends on underlying disease progression rather than surgical technique alone. For eyes with advanced Müller cell degeneration, alternative closure materials should be considered. This case highlights the critical role of vascular and structural 3D imaging in evaluating cellular function and predicting surgical outcomes.