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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 -
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 -
The Cochrane Database of Systematic... Aug 2023Macular hole (MH) is a full-thickness defect in the central portion of the retina that causes loss of central vision. According to the usual definition, a large MH has a... (Review)
Review
BACKGROUND
Macular hole (MH) is a full-thickness defect in the central portion of the retina that causes loss of central vision. According to the usual definition, a large MH has a diameter greater than 400 µm at the narrowest point. For closure of MH, there is evidence that pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling achieves better anatomical outcomes than standard PPV. PPV with ILM peeling is currently the standard of care for MH management; however, the failure rate of this technique is higher for large MHs than for smaller MHs. Some studies have shown that the inverted ILM flap technique is superior to conventional ILM peeling for the management of large MHs.
OBJECTIVES
To evaluate the clinical effectiveness and safety of pars plana vitrectomy with the inverted internal limiting membrane flap technique versus pars plana vitrectomy with conventional internal limiting membrane peeling for treating large macular holes, including idiopathic, traumatic, and myopic macular holes.
SEARCH METHODS
The Cochrane Eyes and Vision Information Specialist searched CENTRAL, MEDLINE, Embase, two other databases, and two trials registries on 12 December 2022.
SELECTION CRITERIA
We included randomized controlled trials (RCTs) that evaluated PPV with ILM peeling versus PPV with inverted ILM flap for treatment of large MHs (with a basal diameter greater than 400 µm at the narrowest point measured by optical coherence tomography) of any type (idiopathic, traumatic, or myopic).
DATA COLLECTION AND ANALYSIS
We used standard methodological procedures expected by Cochrane and assessed the certainty of the body of evidence using GRADE.
MAIN RESULTS
We included four RCTs (285 eyes of 275 participants; range per study 24 to 91 eyes). Most participants were women (63%), and of older age (range of means 59.4 to 66 years). Three RCTs were single-center trials, and the same surgeon performed all surgeries in two RCTs (the third single-center RCT did not report the number of surgeons). One RCT was a multicenter trial (three sites), and four surgeons performed all surgeries. Two RCTs took place in India, one in Poland, and one in Mexico. Maximum follow-up ranged from three months (2 RCTs) to 12 months (1 RCT). No RCTs reported conflicts of interest or disclosed financial support. All four RCTs enrolled people with large idiopathic MHs and compared conventional PPV with ILM peeling versus PPV with inverted ILM flap techniques. Variations in technique across the four RCTs were minimal. There was some heterogeneity in interventions: in two RCTs, all participants underwent combined cataract-PPV surgery, whereas in one RCT, some participants underwent cataract surgery after PPV (the fourth RCT did not mention cataract surgery). The critical outcomes for this review were mean best-corrected visual acuity (BCVA) and MH closure rates. All four RCTs provided data for meta-analyses of both critical outcomes. We assessed the risk of bias for both outcomes using the Cochrane risk of bias tool (RoB 2); there were some concerns for risk of bias associated with lack of masking of outcome assessors and selective reporting of outcomes in all RCTs. All RCTs reported postoperative BCVA values; only one RCT reported the change in BCVA from baseline. Based on evidence from the four RCTs, it is unclear if the inverted ILM flap technique compared with ILM peeling reduces (improves) postoperative BCVA measured on a logarithm of the minimum angle of resolution (logMAR) chart at one month (mean difference [MD] -0.08 logMAR, 95% confidence interval [CI] -0.20 to 0.05; P = 0.23, I = 65%; 4 studies, 254 eyes; very low-certainty evidence), but it may improve BCVA at three months or more (MD -0.17 logMAR, 95% CI -0.23 to -0.10; P < 0.001, I = 0%; 4 studies, 276 eyes; low-certainty evidence). PPV with an inverted ILM flap compared to PPV with ILM peeling probably increases the proportion of eyes achieving MH closure (risk ratio [RR] 1.10, 95% CI 1.02 to 1.18; P = 0.01, I = 0%; 4 studies, 276 eyes; moderate-certainty evidence) and type 1 MH closure (RR 1.31, 95% CI 1.03 to 1.66; P = 0.03, I² = 69%; 4 studies, 276 eyes; moderate-certainty evidence). One study reported that none of the 38 participants experienced postoperative retinal detachment.
AUTHORS' CONCLUSIONS
We found low-certainty evidence from four small RCTs that PPV with the inverted ILM flap technique is superior to PPV with ILM peeling with respect to BCVA gains at three or more months after surgery. We also found moderate-certainty evidence that the inverted ILM flap technique achieves more overall and type 1 MH closures. There is a need for high-quality multicenter RCTs to ascertain whether the inverted ILM flap technique is superior to ILM peeling with regard to anatomical and functional outcomes. Investigators should use the standard logMAR charts when measuring BCVA to facilitate comparison across trials.
Topics: Female; Humans; Male; Cataract; Multicenter Studies as Topic; Myopia; Retina; Retinal Perforations; Retrospective Studies; Tomography, Optical Coherence; Visual Acuity; Vitrectomy
PubMed: 37548231
DOI: 10.1002/14651858.CD015031.pub2 -
The Cochrane Database of Systematic... May 2023Vitrectomy is an established treatment for the complications of proliferative diabetic retinopathy (PDR). However, a number of complications can occur during and after... (Review)
Review
BACKGROUND
Vitrectomy is an established treatment for the complications of proliferative diabetic retinopathy (PDR). However, a number of complications can occur during and after vitrectomy for PDR. These include bleeding and the creation of retinal holes during surgery, and bleeding, retinal detachment and scar tissue on the retina after surgery. These complications can limit vision, require further surgery and delay recovery. The use of anti-vascular endothelial growth factor (anti-VEGF) agents injected into the eye before surgery has been proposed to reduce the occurrence of these complications. Anti-VEGF agents can reduce the amount and vascularity of abnormal new vessels associated with PDR, facilitating their dissection during surgery, reducing intra- and postoperative bleeding, and potentially improving outcomes.
OBJECTIVES
To assess the effects of perioperative anti-VEGF use on the outcomes of vitrectomy for the treatment of complications for proliferative diabetic retinopathy (PDR).
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL; which contains the Cochrane Eyes and Vision Trials Register; 2022, Issue 6); Ovid MEDLINE; Ovid Embase; the ISRCTN registry; ClinicalTrials.gov and the WHO ICTRP. The date of the search was 22 June 2022.
SELECTION CRITERIA
We included randomised controlled trials (RCTs) that looked at the use of anti-VEGFs and the incidence of complications in people undergoing vitrectomy for PDR. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed and extracted the data. We used the standard methodological procedures expected by Cochrane. The critical outcomes of the review were the mean difference in best corrected visual acuity (BCVA) between study arms at six (± three) months after the primary vitrectomy, the incidence of early postoperative vitreous cavity haemorrhage (POVCH, within four weeks postoperatively), the incidence of late POVCH (occurring more than four weeks postoperatively), the incidence of revision surgery for POVCH within six months, the incidence of revision surgery for recurrent traction/macular pucker of any type and/or rhegmatogenous retinal detachment within six months and vision-related quality of life (VRQOL) measures. Important outcomes included the proportion of people with a visual acuity of counting fingers (1.8 logMAR or worse), the number of operative retinal breaks reported and the frequency of silicone oil tamponade required at time of surgery.
MAIN RESULTS
The current review includes 28 RCTs that looked at the pre- or intraoperative use of intravitreal anti-VEGFs to improve the outcomes of pars plana vitrectomy for complications of PDR. The studies were conducted in a variety of countries (11 from China, three from Iran, two from Italy, two from Mexico and the remaining studies from South Korea, the UK, Egypt, Brazil, Japan, Canada, the USA, Indonesia and Pakistan). The inclusion criteria for entry into the studies were the well-recognised complications of proliferative retinopathy: non-clearing vitreous haemorrhage, tractional retinal detachment involving the macula or combined tractional rhegmatogenous detachment. The included studies randomised a total of 1914 eyes. We identified methodological issues in all of the included studies. Risk of bias was highest for masking of participants and investigators, and a number of studies were unclear when describing randomisation methods and sequence allocation. Participants receiving intravitreal anti-VEGF in addition to pars plana vitrectomy achieved better BCVA at six months compared to people undergoing vitrectomy alone (mean difference (MD) -0.25 logMAR, 95% confidence interval (CI) -0.39 to -0.11; 13 studies, 699 eyes; low-certainty evidence). Pre- or intraoperative anti-VEGF reduced the incidence of early POVCH (12% versus 31%, risk ratio (RR) 0.44, 95% CI 0.34 to 0.58; 14 studies, 1038 eyes; moderate-certainty evidence). Perioperative anti-VEGF use was also associated with a reduction in the incidence of late POVCH (10% versus 23%, RR 0.47, 95% CI 0.30 to 0.74; 11 studies, 579 eyes; high-certainty evidence). The need for revision surgery for POVCH occurred less frequently in the anti-VEGF group compared with control, but the confidence intervals were wide and compatible with no effect (4% versus 13%, RR 0.44, 95% CI 0.15 to 1.28; 4 studies 207 eyes; moderate-certainty evidence). Similar imprecisely measured effects were seen for revision surgery for rhegmatogenous retinal detachment (5% versus 11%, RR 0.50, 95% CI 0.15 to 1.66; 4 studies, 145 eyes; low-certainty evidence). Anti-VEGFs reduce the incidence of intraoperative retinal breaks (12% versus 31%, RR 0.37, 95% CI 0.24 to 0.59; 12 studies, 915 eyes; high-certainty evidence) and the need for silicone oil (19% versus 41%, RR 0.46, 95% CI 0.27 to 0.80; 10 studies, 591 eyes; very low-certainty evidence). No data were available on quality of life outcomes or the proportion of participants with visual acuity of counting fingers or worse.
AUTHORS' CONCLUSIONS
The perioperative use of anti-VEGF reduces the risk of late POVCH, probably results in lower early POVCH risk and may improve visual outcomes. It also reduces the incidence of intraoperative retinal breaks. The evidence is very uncertain about its effect on the need for silicone oil tamponade. The reported complications from its use appear to be low. Agreement on variables included and outcome standardisation is required in trials studying vitrectomy for PDR.
Topics: Humans; Diabetes Mellitus; Diabetic Retinopathy; Endothelial Growth Factors; Postoperative Hemorrhage; Retinal Detachment; Retinal Perforations; Silicone Oils; Vitrectomy
PubMed: 37260074
DOI: 10.1002/14651858.CD008214.pub4 -
Canadian Journal of Ophthalmology.... Jun 2024To compare the best-corrected visual acuity (BCVA) change, idiopathic macular (IMH) closure, and complications in IMH patients receiving combined phacovitrectomy and... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
To compare the best-corrected visual acuity (BCVA) change, idiopathic macular (IMH) closure, and complications in IMH patients receiving combined phacovitrectomy and sequential surgery (vitrectomy followed by phacoemulsification).
DESIGN
Systematic review and meta-analysis.
METHODS
PubMed, Ovid EMBASE, and Cochrane Library databases were searched from their inception through February 2022. Randomized, controlled trials and observational studies that presented results of BCVA change, IMH closure, and surgery-related complications were included. A random-effects meta-analysis was conducted to calculate effect estimates with 95% CIs.
RESULTS
One randomized, controlled trials and 7 cohort studies with 585 patients were included. Overall, the meta-analyses of BCVA change (mean difference, -0.03; 95% CI, -0.10-0.04) and IMH closure (risk ratio = 1.04; 95% CI, 0.96-1.13) revealed no significant differences between combined phacovitrectomy and sequential surgery. The pooled risk ratios for various surgical complications such as postoperative retinal detachment, inflammation, and intraocular pressure elevation showed no significant differences between the 2 groups.
CONCLUSIONS
Similar visual gain and IMH closure rates were achieved after both combined phacovitrectomy and sequential surgery, with similar complication risks. The anatomic and functional outcomes of combined surgery were not better than those of sequential surgery. These results could serve as a reference for future trials.
Topics: Humans; Vitrectomy; Retinal Perforations; Visual Acuity; Phacoemulsification; Postoperative Complications
PubMed: 37253430
DOI: 10.1016/j.jcjo.2023.05.005