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International Journal of Retina and... Jun 2024Macular holes (MHs), including atraumatic idiopathic and refractory MHs, affect central vision acuity due to full-thickness defects in the retinal tissue. The existing... (Review)
Review
Macular holes (MHs), including atraumatic idiopathic and refractory MHs, affect central vision acuity due to full-thickness defects in the retinal tissue. The existing controversy regarding the pathophysiology and management of MHs has significantly improved with the implementation of internal limiting membrane (ILM) surgical techniques and improved MH closure rates. Thus, to determine the effect of ILM techniques on large idiopathic and refractory MH management, the present study systematically reviewed 5910 original research articles extracted from online literature databases, including PubMed, Cochrane, Google Scholar, and Embase, following the PRISMA guidelines. The primary outcome measures were MH closure rate and postoperative visual acuity. A total of 23 randomized controlled trials (RCTs) with adequate patient information and information on the effect of ILM peeling, inverted ILM flaps, autologous retinal transplantation (ART), and ILM insertion techniques on large idiopathic and refractory MH patients were retrieved and analyzed using RevMan software (version 5.3) provided by the Cochrane Collaboration. Statistical risk of bias analysis was also conducted on the selected sources using RoB2, which showed a low risk of bias in the included studies. A meta-analysis indicated that the inverted ILM flap technique had a significantly greater MH closure rate for primary MH than the other treatment methods (OR = 3. 22, 95% CI 1.34-7.43; p = 0.01). Furthermore, the findings showed that the inverted ILM flap group had significantly better postoperative visual acuity than did the other treatment options for patients with idiopathic MH (WMD = - 0.13; 95% CI = 0.22-0.09; p = 0.0002). The ILM peeling technique had the second highest statistical significance for MH closure rates in patients with idiopathic MH (OR = 2. 72, 95% CI: 1.26-6.32; p = 0.016). In refractory MHs, autologous retinal transplant (ART) and multilayer ILM plug (MIP) techniques improve the closure rate and visual function; human amniotic membrane grafting (hAMG) provides a high degree of anatomical outcomes but disappointing visual results. This study demonstrated the reliability and effectiveness of ILM techniques in improving the functional and anatomical outcomes of large idiopathic and refractory MH surgery. These findings will help clinicians choose the appropriate treatment technique for patients with idiopathic and refractory MH.
PubMed: 38907361
DOI: 10.1186/s40942-024-00564-2 -
American Journal of Ophthalmology May 2024The optimal management of pediatric traumatic macular holes (TMH) is unclear from lack of prospective randomized trials. The literature is divided into early (≤1month... (Review)
Review
PURPOSE
The optimal management of pediatric traumatic macular holes (TMH) is unclear from lack of prospective randomized trials. The literature is divided into early (≤1month post-trauma), delayed (>1 month) pars plana vitrectomy (PPV), and observation. Our aim is to find which group can achieve best-superior spectacle corrected visual acuity (VA), visual gain, and time for hole closure.
DESIGN
Systematic review.
METHODS
This systematic review was registered with PROSPERO (ID:CRD42022383134). The databases searched from inception until July 31, 2023, were MEDLINE OVID, Scopus, Web of Science, Embase, and Google Scholar. The articles were screened for title and abstract then for full text. Risk of bias was also assessed. Three outcome measures were analyzed: final VA, visual gain, and time to closure of macular hole (MH). MH size was divided into small (≤250 µm), medium (>250-500 µm), and large (>500 µm).
RESULTS
Ninety eight (98) studies with 234 patients in the PPV group and 87 patients in the observation group were included in the review. Final VA (logarithm of the minimum angle of resolution) and visual gain were respectively in PPV vs observation groups: (1) small MH 0.37 ± 0.52 vs 0.42 ± 0.56 (P = .484) and -0.96 ± 0.83 vs -0.49 ± 0.40 (P = .005); (2) medium MH 0.58 ± 0.39 vs 0.34 ± 0.34 (P = .06) and -0.36 ± 0.42 vs -0.74 ± 0.44 (P < .001); (3) large MH 0.62 ± 0.42 vs 0.59 ± 0.35 (P = .337) and -0.31 ± 0.48 vs -0.62 ± 0.37 (P = .11). Small TMH had comparable closure time: 3.21 ± 2.52 months vs 3.49 ± 4.43 (P = .954) in the PPV and observation groups. Early and late PPV yielded comparable final VA 0.67 ± 0.66 vs 0.54 ± 0.35 (P = .576) and visual gain -0.58 ± 0.69 vs -0.49 ± 0.48 (P = .242) in the PPV and observation groups.
CONCLUSIONS
PPV was very effective in closing TMH and VA gain in children throughout a wide range of hole size. Early and delayed PPV yielded similar anatomic and visual results. Observation and PPV yielded comparable final VA and closure time. Clinicians can choose either early PPV or delayed PPV when healing biomarkers are absent on periodic optical coherence tomography.
PubMed: 38710352
DOI: 10.1016/j.ajo.2024.05.001 -
PloS One 2024To evaluate the efficacy of inverted internal limiting membrane (ILM) flap technique in full-thickness macular holes (MHs) with a size of ≤400 μm compared to the ILM... (Meta-Analysis)
Meta-Analysis
PURPOSE
To evaluate the efficacy of inverted internal limiting membrane (ILM) flap technique in full-thickness macular holes (MHs) with a size of ≤400 μm compared to the ILM peeling technique.
METHODS
Related literatures that compared inverted ILM flap and ILM peeling in MHs ≤ 400 μm were reviewed by searching electronic databases including Pubmed, EMbase, ClinicalTrials.gov, and Cochrane Library up to April 2023. The primary outcome measure was hole closure rate, and the secondary outcome measures were the mean postoperative best-corrected visual acuity (BCVA), retinal sensitivity, and outer status of the retinal layers, including the external limiting membrane and ellipsoid zone. The quality of the articles was assessed according to the revised version of the Cochrane risk-of-bias tool for randomized trials or the Newcastle-Ottawa scale. In the case of heterogeneity, a sensitivity analysis was conducted, and publication bias was visually evaluated using a funnel plot.
RESULTS
This review included six studies with 610 eyes for the primary outcome and 385 eyes for the secondary outcomes, which were two randomized control trials and four retrospective studies. Pooled data revealed that the overall MH closure rate was 99.4% in the inverted ILM flap group and 96.2% in the ILM peeling group, without significant difference between the two groups (odds ratio = 3.91; 95% confidence interval, 0.82~18.69; P = 0.09). The inverted ILM flap technique did not have a favorable effect on the BCVA, retinal sensitivity, or recovery of the outer retinal layers. These results were consistent with those of the subgroup analysis of the different follow-up periods. No significant publication bias was observed.
CONCLUSION
In eyes with MHs of ≤400 μm, both techniques demonstrated excellent surgical outcomes without significant differences. Therefore, surgical techniques can be selected according to surgeon preferences.
Topics: Retinal Perforations; Humans; Surgical Flaps; Visual Acuity; Vitrectomy; Treatment Outcome
PubMed: 38683767
DOI: 10.1371/journal.pone.0302481 -
International Ophthalmology Mar 2024It is commonly accepted that phacoemulsification surgery is a risk factor for the development of posterior vitreous detachment (PVD) and may accelerate the process. This...
PURPOSE
It is commonly accepted that phacoemulsification surgery is a risk factor for the development of posterior vitreous detachment (PVD) and may accelerate the process. This is an important consideration particularly in cases involving young patients who pre-operatively have no PVD, given the increased risk of retinal tears and detachments.
METHODS
A comprehensive literature search was conducted to identify studies reporting incidence of PVD post-uncomplicated phacoemulsification surgery. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement was used for search strategy. Of 3071 titles, 7 studies met the inclusion criteria; The outcomes measured were PVD occurrence by (1) time, (2) type, (3) age, (4) gender and (5) axial length, with all statistical analysis performed using Review Manager.
RESULTS
A total of 2034 eyes were included for analysis with a mean follow-up time of 28.3 months. 33.3% of patients developed a PVD, either partial or complete, with rates increasing in a time dependent manner. No significant difference was noted in sub-group analysis by age, gender or axial length.
CONCLUSIONS
The results from our systematic review show that uncomplicated phacoemulsification accelerates the physiological process of PVD development. Pre-operative evaluation of the vitreoretinal interface should be performed with careful post-operative follow-up advised in those without a pre-existing PVD.
Topics: Humans; Vitreous Detachment; Phacoemulsification; Prospective Studies; Vitreous Body; Retinal Perforations; Retinal Detachment
PubMed: 38512501
DOI: 10.1007/s10792-024-03091-z -
International Journal of Retina and... Feb 2024Toxoplasma gondii causes ocular toxoplasmosis (OT), involving inflammation, scarring, and retinal complications. The OT complications were retinal detachment (RD), and... (Review)
Review
BACKGROUND
Toxoplasma gondii causes ocular toxoplasmosis (OT), involving inflammation, scarring, and retinal complications. The OT complications were retinal detachment (RD), and retinal breakage (RB). Surgical interventions like scleral buckling (SB) and vitrectomy are common. Limited understanding exists of the safety and efficacy of surgical management of RD/RB secondary to OT. Another complication is toxoplasmosis-related macular holes (tMH), with sparse evidence on surgical outcomes. This meta-analysis aims to clarify clinical characteristics, and surgical results, and enhance understanding of RD, RB, and MH secondary to OT.
METHODS
PubMed, Cochrane, Embase and Web of Science database were queried for retrospective studies, case series and case reports that provided information on RD, RB and MH associated with OT and reported the outcomes of: (1) Retinal reattachment of RD/RB and tMH closure; (2) Best-corrected visual acuity (BCVA) improvement; and (3) Complications. Heterogeneity was examined with I statistics. A random-effects model was used for outcomes with high heterogeneity. Statistical analysis was performed using the software R (version 4.2.3, R Foundation for Statistical Computing, Vienna, Austria).
RESULTS
Fourteen final studies, comprising a total of 96 patients were analyzed, 81 with RD or RB and 15 with tMH. Overall, surgical management was associated with several advantages: a high rate of retinal reattachment of RD/RB of 97% (95% Confidence Interval [CI] 92-100%; I = 0%), retinal reattachment of just RD of 96% (95% CI 89-100%; I = 30%) and tMH closure 97% (95% CI 87-100; I = 12%). There were significant differences in BCVA after surgeries in studies of RD/RB (MD 0.60; 95% CI 0.35-0.65; I = 20%) and MH (MD 0.67; 95% CI 0.50-0.84; I = 0%). The overall complication rate associated with surgical procedures in RD/RB secondary to OT was confirmed to be 25%.
CONCLUSIONS
The systematic review and meta-analysis showed that the treatment approaches currently in use are effective, with a remarkable rate of retinal reattachment of RD/RB, tMH closure, and substantial improvements in visual acuity. More randomized, long-term studies on disease and surgical factors can provide valuable insights into their impact on anatomical and visual outcomes.
PubMed: 38424638
DOI: 10.1186/s40942-024-00540-w -
Retina (Philadelphia, Pa.) Mar 2024To compare the efficacy and safety of pars plana vitrectomy with and without internal limiting membrane (ILM) peeling for macular hole (MH). (Meta-Analysis)
Meta-Analysis
PURPOSE
To compare the efficacy and safety of pars plana vitrectomy with and without internal limiting membrane (ILM) peeling for macular hole (MH).
METHODS
A systematic literature search on Ovid MEDLINE, Embase, Cochrane Library, and Google Scholar was performed from January 2000 to 2023. The primary outcome was the final best-corrected visual acuity (BCVA). Secondary outcomes included MH closure rates and the need for repeat surgery. The authors performed a random-effects meta-analysis on Review Manager 5.4.
RESULTS
Fourteen studies on 880 eyes were included. Pars plana vitrectomy with and without ILM peel achieved a similar final BCVA ( P = 0.66). However, pars plana vitrectomy without ILM peeling achieved a significantly better final BCVA in eyes with closed MHs (WMD = 0.05 logMAR, 95% CI, 0.01-0.10, P = 0.02). Pars plana vitrectomy with ILM peeling achieved a significantly higher primary MH closure rate (RR = 1.21, 95% CI, 1.04-1.42, P = 0.02) and lower incidence of MH reoperation (RR = 0.19, 95% CI, 0.11-0.33, P < 0.001). The final MH closure rate ( P = 0.12) and incidence of MH recurrence ( P = 0.25) were similar between groups.
CONCLUSION
Pars plana vitrectomy with and without ILM peel achieved a similar final BCVA. However, pars plana vitrectomy without ILM peeling achieved a better final BCVA in eyes with closed MHs. ILM peeling achieved a greater primary MH closure rate and reduced need for reoperation.
Topics: Humans; Vitrectomy; Retinal Perforations; Retina; Reoperation; Visual Acuity; Basement Membrane; Retrospective Studies; Epiretinal Membrane
PubMed: 38166007
DOI: 10.1097/IAE.0000000000004033 -
The Cochrane Database of Systematic... Nov 2023Macular holes cause severe impairment of sight. With the aim of improving the outcome of surgery for macular holes, particularly larger macular holes (those measuring... (Review)
Review
BACKGROUND
Macular holes cause severe impairment of sight. With the aim of improving the outcome of surgery for macular holes, particularly larger macular holes (those measuring over 400 μm), a variable period of face-down positioning may be advised. This review is an update of a Cochrane Review published in 2011.
OBJECTIVES
To evaluate the effect of postoperative face-down positioning on the outcome of surgery for macular hole.
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2022, Issue 5), which contains the Cochrane Eyes and Vision Trials Register, Ovid MEDLINE, Ovid Embase, the ISRCTN registry, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform. There were no date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 25 May 2022.
SELECTION CRITERIA
We included randomised controlled trials (RCTs) in which postoperative face-down positioning was compared to no face-down positioning following surgery for macular holes. The primary outcome of interest was closure of the macular hole. Other outcomes of interest included visual outcomes, quality of life outcomes, and the occurrence of adverse events. Pairs of review authors independently selected studies for inclusion, extracted data, assessed risk of bias, and evaluated the certainty of evidence using GRADE.
DATA COLLECTION AND ANALYSIS
We used standard methodological procedures expected by Cochrane. We analysed dichotomous data as risk ratios (RRs), and continuous data as mean differences (MDs), with 95% confidence intervals (CI). The unit of analysis was eyes.
MAIN RESULTS
We included eight studies allocating a total of 709 eyes (699 participants). There was heterogeneity in study design, including the control group treatment (from no positioning to strict maintenance of other 'face-forward' postures) and surgical procedures (with or without inner limiting membrane peeling, with or without cataract surgery). There were also different durations of positioning, with two studies using 3 days, two studies using 5 days, and three studies using 10 days of face-down positioning. Whilst the overall risk of bias was low, all included studies were judged to be at high or unclear risk of bias due to absence of assessment of adherence to the 'prescribed' intervention of face-down positioning or posturing. The primary outcome of successful anatomical hole closure at one to six months following surgery was reported in 95 of every 100 eyes of participants advised to position face-down for at least three days after surgery, and in 85 of every 100 eyes of participants not advised to position face-down (RR 1.05, 95% CI 0.99 to 1.12, 709 eyes, 8 studies, I² = 44%). Amongst the 327 eyes of participants with macular holes of at least 400 μm, hole closure was noted in 94 of every 100 eyes of participants advised to position face-down, and in 84 of every 100 eyes of participants not advised to position face-down (RR 1.08, 95% CI 0.93 to 1.26, 5 studies, I² = 62%). Amongst the 129 eyes of participants with macular holes of less than 400 μm, hole closure was noted in 100 of every 100 eyes of participants advised to position face-down, and in 96 of every 100 eyes of participants not advised to position face-down (RR 1.03, CI 0.97 to 1.11, 4 studies, I² = 0%). The certainty of the evidence was low, downgraded for imprecision (CIs including no effect) and study design limitations (with different durations of face-down posturing used in the absence of a dose-response gradient, and limitations in measuring the exposure). Meta-analysis of visual acuity data was challenging given the use of different definitions of postoperative visual outcome across studies. Three studies reported findings by gain in Early Treatment Diabetic Retinopathy Study (ETDRS) letters (MD 2.04, 95% CI -0.01 to 4.09, very low-certainty evidence). Meta-analyses of quality of life data were not possible because of inconsistency in outcome metrics across studies. One study reported no difference between groups in quality of life, as reported on a validated quality of life metric scale (the National Eye Institute Visual Function Questionnaire - 25 (NEI VFQ-25), between face-down positioning for five days and non-face-down positioning (median NEI VFQ-25 score was 89 (interquartile range (IQR) 76 to 94) in the face-down group versus 87 (IQR 73 to 93) in the non-face-down group (adjusted mean difference on a logistic scale 0.02, 95% CI -0.03 to 0.07, P = 0.41)). Two studies reported increased ease of positioning and less pain in non-face-down positioning groups on non-validated 0-to-10-point visual analogue scores. On an ease-of-positioning score running from 0 (very difficult) to 10 (very easy), there were consistent reports of the discomfort associated with face-down positioning: the median participant-reported ease-of-positioning score was 6 (IQR 4 to 8) in those undergoing 5 days of face-down positioning versus 9 (IQR 7 to 10) in the comparator group (P = 0.01). On a pain score with 0 being pain-free and 10 being in severe pain, mean pain score was 6.52 ± 2.48 in the face-down positioning group versus 2.53 ± 2.6 in the non-face-down positioning group. The adverse event of postoperative nerve compression occurred in less than 1 in every 100 (3 per 1000) participants advised to position face-down, and 0 in every 100 participants not advised to position face-down (699 participants, 8 studies, moderate-certainty evidence).
AUTHORS' CONCLUSIONS
We identified eight RCTs evaluating face-down positioning following surgery for macular hole. The included studies were not all directly comparable due to differences in the surgical techniques used and the durations of postoperative positioning advised. Low-certainty evidence suggests that face-down positioning may have little or no effect on macular hole closure after surgery. Face-down positioning is a low-risk intervention, with serious adverse events affecting fewer than 1 in 300 people. We suggest that any future trials focus on patients with larger macular holes, with interventions and outcome measures used in previous trials (i.e. with inner limiting membrane peeling, positioning durations of three to five days, and validated quality of life metrics) to allow future meta-analyses to determine any effect with greater precision and confidence.
Topics: Humans; Cataract Extraction; Diabetic Retinopathy; Pain; Retinal Perforations
PubMed: 37987517
DOI: 10.1002/14651858.CD008228.pub3 -
Ophthalmic Research 2023The inverted internal limiting membrane (ILM) flap technique was initially developed for the closure of large macular holes (MHs). However, its efficacy in treating... (Meta-Analysis)
Meta-Analysis
INTRODUCTION
The inverted internal limiting membrane (ILM) flap technique was initially developed for the closure of large macular holes (MHs). However, its efficacy in treating small holes has been a matter of debate. This study aimed to compare the anatomical and visual outcomes of vitrectomy (PPV) combined with the inverted ILM flap and ILM peeling in cases of small and medium-sized MHs.
METHODS
A meta-analysis was conducted by searching the relevant literature in databases, including PubMed, Web of Science, Embase, and Cochrane Library. The search included articles published from the inception of the databases up until January 2023. The inclusion criteria limited the studies to only experimental-based research. The heterogeneity, publication bias, and sensitivity analysis were performed to ensure the statistical power and reliability of the analysis.
RESULTS
Five studies, including two non-randomized concurrent control trials and three non-randomized concurrent control trials, comprising a total of 269 eyes, were analysed. The results showed no significant difference in the MH closure rate between the two groups (odds ratio (OR) = 0.29, 95% confidence interval: 0.04-1.96, p = 0.33). Furthermore, there were no significant differences observed in visual acuity, external limiting membrane (ELM), and ellipsoid zone (EZ) integrity at 3 months (ELM OR = 0.88, EZ OR = 0.85) or 12 months (ELM OR = 0.96, EZ OR = 1.39) post-operation between the two groups.
CONCLUSION
The surgical repair of MHs smaller than 400 μm with ILM flap seems to be similar in visual acuity improvement and anatomical recovery compared to the traditional technique.
Topics: Humans; Retinal Perforations; Reproducibility of Results; Basement Membrane; Retina; Vitrectomy; Retrospective Studies; Tomography, Optical Coherence
PubMed: 37931613
DOI: 10.1159/000534873 -
Retina (Philadelphia, Pa.) Nov 2023To summarize the current evidence regarding the therapeutic effect of using autologous platelet concentrate (APC) in vitrectomy for macular hole (MH). (Meta-Analysis)
Meta-Analysis
PURPOSE
To summarize the current evidence regarding the therapeutic effect of using autologous platelet concentrate (APC) in vitrectomy for macular hole (MH).
METHODS
The PubMed, Web of Science, and Embase databases were searched according to the PROSPERO protocol (CRD42022366202). Controlled trials comparing whether APC was used in the vitrectomy of MH were included. The primary outcome was the closure rate of MH and postoperative best-corrected visual acuity, and the secondary outcome was the incidence of different types of complications.
RESULTS
Seven studies that included 634 eyes were eligible. For the primary outcome, the usage of APC significantly improved the closure rate of MH in vitrectomy (odds ratio [OR] = 5.34, 95% confidence interval, 2.83-10.07, P < 0.001). Postoperative visual acuity did not significantly differ between the APC group and similar baseline controls (SMD = -0.07, 95% confidence interval, -0.35 to 0.22, P = 0.644). For the secondary outcome, using APC did not result in additional complications regarding postoperative retinal detachment or the recurrence of MH.
CONCLUSION
The use of APC in vitrectomy was associated with a superior closure rate of the hole and no additional complications; therefore, it is effective and safe in MH surgery.
Topics: Humans; Retinal Perforations; Vitrectomy; Endotamponade; Retinal Detachment; Eye; Retrospective Studies
PubMed: 37607135
DOI: 10.1097/IAE.0000000000003888 -
Ophthalmic Research 2023Although internal limiting membrane (ILM) peeling facilitates macular hole (MH) closure and reduces late hole reopening, it brings some detrimental consequences to the... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Although internal limiting membrane (ILM) peeling facilitates macular hole (MH) closure and reduces late hole reopening, it brings some detrimental consequences to the retinal microstructure and functional outcomes. So far, previous studies have not reached a consensus on the optimal ILM peeling size.
OBJECTIVES
The objective of this study was to evaluate the outcomes of different ILM peeling sizes for idiopathic MHs.
METHODS
PubMed, Embase, Cochrane Library, Web of Science, CNKI, and WANFANG were searched until April 10, 2022. Studies in English or Chinese that compare the effects of two ILM peeling sizes (>2 disk diameters [DDs] vs. ≤2DD) for idiopathic MHs were included. The overall closure rate, postoperative best-corrected visual acuity (BCVA), type 1 closure, and adverse events were extracted. BCVA was converted to logarithm of the minimum angle of resolution (LogMAR).
RESULTS
Seven eligible studies (560 eyes) including 3 randomized clinical trials, 3 prospective trials, and one retrospective cohort were included. Pooled results showed a significantly better postoperative BCVA (mean difference = -0.16; 95% confidence interval [CI]: -0.27 to -0.04; LogMAR) and higher type 1 closure rate (risk ratio [RR] = 1.24; 95% CI: 1.08-1.43) in eyes with ILM peeling >2DD than those with peeling ≤2DD. No significant difference was found in overall closure rate and adverse events between the two groups. Subgroup analysis indicated that in MHs >400 μm, peeling >2DD helped obtain a better postoperative BCVA (mean difference = -0.17; 95% CI: -0.29 to -0.04; LogMAR) and higher frequency of type 1 closure (RR = 1.25; 95% CI: 1.03-1.51).
CONCLUSIONS
Peeling >2DD shares similar safety level with peeling ≤2DD and has a superiority of facilitating visual recovery. Larger ILM peeling may be more beneficial for large MHs.
Topics: Humans; Retinal Perforations; Retrospective Studies; Prospective Studies; Vitrectomy; Treatment Outcome; Visual Acuity; Basement Membrane; Epiretinal Membrane; Tomography, Optical Coherence
PubMed: 37586342
DOI: 10.1159/000531510