FIRST FAILED MACULAR HOLE SURGERY OR REOPENING OF A PREVIOUSLY CLOSED HOLE: Do We Gain by Reoperating?-A Systematic Review and Meta-analysis

Abstract

Purpose: To evaluate repeated surgery for idiopathic full-thickness macular hole that failed to close (FTC) after first surgery or reopened (RO) once originally closed.

Methods: Systematic review and meta-analysis. Pubmed.gov and Cochrane Library were searched for studies in English presenting outcomes of idiopathic full-thickness macular hole that FTC or RO (case reports/series of <5 cases excluded).

Outcome measures: Anatomical closure, postoperative best-corrected visual acuity, intraoperative/postoperative complications, and patient-reported outcomes. Meta-analysis was performed on aggregate and available individual participant data sets using the metafor package in R.

Results: Twenty-eight eligible studies were identified. After reoperation, pooled estimates for anatomical closure were 78% (95% confidence interval 71-84%) and 80% (95% confidence interval 66-89%) for FTC and RO groups, respectively. On average, best-corrected visual acuity improved in both groups. However, only 15% (28 of 189 eyes) of FTC eyes achieved best-corrected visual acuity of ≥6/12. The pooled estimated probability of ≥2-line best-corrected visual acuity improvement was 58% in the FTC group (95% confidence interval 45-71%); meta-analysis was not possible in the RO group. The most common complication was cataract.

Conclusion: Reoperation for FTC or RO idiopathic full-thickness macular hole achieved a clinically meaningful visual acuity improvement in more than half of patients; high levels of vision (≥6/12), however, were uncommon.

Fig. 1.

Flow diagram of studies identified on iFTMHs that FTC after the primary surgical procedure (FTC, left) and those that initially closed which later reopened (RO, right). *Two studies identified through reference lists of included studies, one study identified after presentation of the systematic review at the Fernie Vitreoretinal Meeting, Fernie, Canada, January 26, 2017, and following discussion with the author.

Fig. 2.

Proportion of iFTMHs that closed after repeated surgery. Estimates and 95% CIs for 26 studies along with overall estimate from meta-analysis and I² measure of among study heterogeneity. Point size is proportional to weighting of individual studies in the meta-analysis.

Fig. 3.

Proportion of iFTMHs exhibiting a ≥2 Snellen line gain in BCVA after repeated surgery. Estimates and 95% CIs for 17 studies along with overall estimate from meta-analysis and I² measure of among study heterogeneity. Point size is proportional to weighting of individual studies in the meta-analysis.

Fig. 4.

Proportion of iFTMHs that closed and then RO after initial surgery that subsequently closed after repeated surgery. Estimates and 95% CIs for four studies along with overall estimate from meta-analysis and I² measure of among study heterogeneity. Point size is proportional to weighting of individual studies in the meta-analysis.