Role of Positioning after Full-Thickness Macular Hole Surgery: A Systematic Review and Meta-Analysis

Minimal Gas Vitrectomy and As-Needed Positioning Duration for Idiopathic Macular Holes

INTRODUCTION

This study aimed to investigate postoperative outcomes of minimal gas vitrectomy (MGV) combined with a reduced period of gas-fovea contact in the management of idiopathic full-thickness macular holes (MHs).

METHODS

This retrospective cohort study included patients who underwent surgery for MHs with minimal hole diameters of 250-800 µm and categorized them into two groups: conventional fluid-gas exchange (FGX) (38 eyes) and MGV (28 eyes), with FGX replaced by a 1.0-1.2 mL injection of pure sulfur hexafluoride after internal limiting membrane peeling. Postoperatively, patients in the MGV group were kept in a face-down position, switching to face-forward or no positioning (pseudophakia) once MH closure was confirmed by optical coherence tomography, performed every few days during the first postoperative week. The maximum duration of face-down positioning was 5 days.

RESULTS

Most baseline characteristics were comparable between the two groups except for the proportion of combined cataract surgery and the use of non-expansile gas, which were higher in the FGX group. Prone positioning time in the MGV group was shorter than that in the control group (3.8 days vs. 11.9 days). Subfoveal fluid pocket was present in 73.0% and 5.2% of eyes in the MGV and FGX groups, respectively. Twenty-seven eyes (96.4%) in the MGV group showed MH closure within 3 months. At 12 months, compared to the FGX group, the MGV group exhibited less disruption of the ellipsoidal zone (28.5% vs. 57.8%), superior visual acuity (0.33 ± 0.18 vs. 0.54 ± 0.28), and comparable MH closure rates.

CONCLUSION

In the treatment of medium-sized MHs, when compared to the FGX method, the use of a smaller volume of gas tamponade may be associated with earlier photoreceptor restoration. This method individualized prone positioning period without an immediate impact on central vision post surgery.

Facedown Positioning in Macular Hole Surgery: A Systematic Review and Individual Participant Data Meta-Analysis

TOPIC

To assess the anatomic and visual effects of facedown positioning (FDP) advice in patients undergoing vitrectomy with gas tamponade for idiopathic full-thickness macular holes (FTMHs) and to explore differential treatment effects by macular hole size and FDP duration.

CLINICAL RELEVANCE

The necessity and duration of FDP for FTMH closure remain contentious, with no consensus guidelines.

METHODS

Prospectively registered systematic review and individual patient data (IPD) meta-analysis of randomized controlled trials comparing FDP with no FDP (nFDP) across the MEDLINE, Embase, and Cochrane Library databases and clinical trial registries from January 2000 to March 2023 (CRD42023395152). All adults with idiopathic FTMHs undergoing vitrectomy with gas tamponade were included. The main outcomes were primary macular hole closure and postoperative visual acuity at 6 months or nearest time point.

RESULTS

Of 8 eligible trials, 5 contributed IPD for 379 eyes and were included in our analysis. The adjusted odds ratio (OR) for primary closure with FDP versus nFDP was 2.41 (95% confidence interval [CI], 0.98-5.93, P = 0.06; low-certainty evidence), translating to a risk ratio (RR) of 1.08 (1.00-1.11) and a number needed to treat (NNT) of 15. The FDP group exhibited a mean improvement in postoperative visual acuity of -0.08 logarithm of the minimum angle of resolution (logMAR) (-0.13 to -0.02, P = 0.006; low-certainty evidence) compared with the nFDP group. Benefits were more certain in participants with larger holes of minimum linear diameter ≥ 400 μm: adjusted OR for closure ranged from 1.13 to 10.12 (P = 0.030) (NNT 12), with a mean visual acuity improvement of -0.18 to -0.01 logMAR (P = 0.022). Each additional day of FDP was associated with improved odds of anatomic success (adjusted OR, 1.02-1.41, RR, 1.00-1.02, P = 0.026) and visual acuity improvement (-0.02 logMAR, -0.03 to -0.01, P = 0.002), possibly plateauing at 3 days.

CONCLUSIONS

This study provides low-certainty evidence that FDP improves the anatomic and visual outcomes of macular hole surgery modestly and indicates that the effect may be more substantial for macular holes exceeding 400 μm. The findings support recommending FDP for patients with macular holes exceeding 400 μm pending further investigation.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Surgeon's perceptions and preferences in the management of idiopathic macular hole

PURPOSE

The management of idiopathic macular holes (iMH) has evolved over time with various modifications in surgical approach. The study aimed to survey the surgeons' preferences in the management of iMH in current times.

DESIGN

Cross-sectional descriptive survey.

METHODS

A 12-item questionnaire addressing the key aspects of iMH management was sent, between October 2022 to November 2022, by personal correspondence to 104 vitreoretinal specialists, actively practicing and performing iMH surgeries at various institutes in India. The responses were gathered till January 2023 and analyzed as per appropriate statistical methods.

RESULTS

Ninety-one retina specialists responded to the survey (response rate of 87.5%) with a median annual surgical load of 30 cases (range: 5-150). Most respondents had similar views on patient selection, combined phaco-vitrectomy, internal limiting membrane (ILM) staining, ILM peel initiation and propagation, tamponade, postoperative positioning, and prognostic factors. The preferred approach for peel initiation was "pinch and peel," but "scrape and peel" was equally recommended for beginners. Most respondents considered iMH >600 microns in size as large and used additional surgical maneuvers for large and failed cases such as ILM flap, large flap, macular detachment, platelet-rich plasma application, and amniotic membrane graft. The three most important visual prognostic factors were duration, preoperative vision, and MH size.

CONCLUSIONS

The practice of surveyed surgeons performing iMH surgery was uniform in several aspects. There is a need to create consensus on the preferred ILM peel technique among trainee surgeons, revisit the iMH size classification, and standardize the surgical approach as per hole size and characteristics.

Macular Hole Surgery as a Historical Perspective

Purpose

To evaluate the outcomes of macular hole (MH) surgery as a historical perspective after its inception in 1991.

Patients and Methods

Retrospective review of 1032 eyes of 949 patients with an idiopathic MH who were followed for at least one year after the initial surgery. All surgeries were performed from 1990 to 2016 by one surgeon (NO) and included phacovitrectomy for patients of ≥40-years-of-age, a removal of the posterior hyaloid and epiretinal membrane, and SF6 gas tamponade with a 1-week face-down. After 1998, internal limiting membrane (ILM) peeling became the conventional procedure. All surgeries were classified into four periods based on the year of the initial surgery. The first period was 1990~1995 (n = 222), the second period was 1996~1999 (n=327), the third period was 2000~2004 (n = 234), and the last period was 2005~2016 (n=249).

Results

The mean follow-up period was 81.3, 79.8, 88.4, and 77.3 months; hole size was 0.33, 0.28, 0.25, and 0.24 disk diameter; hole duration was 15.1, 10.6, 8.2, and 6.1 months; the decimal visual acuity (VA) was 0.13, 0.15, 0.17, and 0.19. The initial closure rate was 61.3, 78.0, 96.6, and 96.4%. The final decimal visual acuity was 0.33, 0.50, 0.66, and 0.79. The rate of a final decimal VA of 0.5 or better was 48.2, 66.4, 82.1, and 88.8%. The rate of a final decimal visual acuity of 1.0 or more was 17.6, 29.3, 43.6, and 58.2%. Multiple regression analyses showed that hole duration and ILM peeling were significantly associated with both the anatomic and functional outcomes.

Conclusion

The favorable outcomes of MH surgery was primarily achieved by earlier surgery and conventional ILM peeling. Favorable results might be obtained using only conventional ILM peeling.

Effect of internal limiting membrane surgical techniques on the idiopathic and refractory management of macular holes: a systematic review and meta-analysis

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.