Macular Hole Repair Surgery Most Successful Within Months of Symptoms

Anatomical and visual outcomes of surgical intervention for idiopathic full thickness macular holes (iFTMH) are inversely related to symptom duration, according to findings of a systematic review and meta-analysis published in Ophthalmology.

Investigators from Newcastle University in the United Kingdom searched publication databases through August 2020 for randomized controlled trials evaluating anatomical and visual outcomes following vitrectomy with gas tamponade for the treatment of iFTMH. A total of 12 articles provided individual participant data through author correspondence.

The total sample size consisted of 940 eyes. Participants were aged median 68 (interquartile range [IQR], 63-72) years, had symptoms of iFTMH for 6 (IQR, 3-10) months prior to surgery, minimum linear diameter (MLD) of the primary iFTMH was 492 (IQR, 400-624) μm, and best-corrected visual acuity (BCVA) was 0.8 logarithm of the minimum angle of resolution (logMAR) at baseline.

During the procedure, 88% of eyes underwent internal limiting membrane (ILM) peeling and 12% ILM flap.

Positive correlations between symptom duration with iFTMH hole size and postoperative BCVA were observed, in which patients with symptoms for 6 months or less before surgery had a mean MLD of 461.4 µm and postoperative BCVA of 0.459 logMAR compared with 680.2 μm and 0.838 logMAR among patients with more than 12 months of symptoms, respectively.

Similarly, the proportion of patients with primary iFTMH closure tended to be related with symptom duration. Patients with symptoms for 3 months or fewer (25.6%) had a closure rate of 88.3%, followed by 85.5% for symptoms of more than 3 to 6 months (31.8%), 78.1% for more than 6 to 12 months (29.9%), 60.5% for more than 12 to 24 months (8.2%), and 73.8% for more than 24 to 72 months (4.5%).

Predictors for primary hole closure include ILM peeling (odds ratio [OR], 18.16; P <.001), ILM flaps (OR, 3.656; P =.001), face down positioning (OR, 2.884; P =.021), MLD (OR, 0.996; P <.001), symptom duration (OR, 0.965; P =.026), and preoperative BCVA (OR, 0.387; P =.008), according to the researchers.

Among the patients who had successful primary hole closure, postoperative BCVA associated with preoperative BCVA (coefficient, 0.366; P <.001), phakic/phakic status (coefficient, 0.108; P =.003), symptom duration (coefficient, 0.008; P <.001), MLD (coefficient, 0.0002; P <.001), ILM flaps (coefficient, -0.092; P =.016), and long-acting gas (coefficient, -0.997; P =.021). Among all patients, predictors for postoperative BCVA of 0.3 logMAR or better were preoperative visual acuity (OR, 2.848; P <.001), symptom duration (OR, 0.65; P =.006), and MLD (OR, 0.003; P <.001).

The major limitation of this analysis was that the studies used a variety of measurement methods and timings to assess iFTMH size and BCVA.

“This individual participant data meta-analysis found that symptom duration was independently associated with both anatomical and visual outcomes for people undergoing surgery for primary iFTMH,” the study authors explain. “Early identification of those affected by this condition, and early intervention which could be achieved by increasing public awareness and improving care pathways, would improve treatment outcomes and should be prioritized by health services.”