Critical Analysis of Macular Hole Repair Techniques: A Comprehensive Systematic Review and Meta-analysis Comparing Internal Limiting Membrane Flap and Internal Limiting Membrane Peeling For Any Size of Macular Hole

Abstract

Abstract Background: Macular holes are a leading cause of visual impairment and blindness worldwide defined as a partial or full thickness anatomical defect in the fovea of the retina. Internal limiting membrane (ILM) peeling is a successful surgical procedure to repair the defect. However, it doesn’t have good efficacy with larger macular holes. Internal limiting membrane (ILM) flap is a novel technique and shows promising results. Objective This systematic review and meta-analysis aims to compare the effectiveness of these two techniques in treating any size and type of macular hole. Methods A comprehensive literature search was conducted in the PubMed, Medline, Cochrane Library and Web of Science databases to identify the relevant articles. The primary outcome measures were MH closure rate and postoperative visual acuity (VA). The statistical power was ensured by performing heterogeneity, publication bias, sensitivity analysis, and subgroup analysis. Pooled odds ratios (ORs), weighted mean difference (WMD), and 95% confidence intervals (CIs) were calculated. Results A total of 8 RCTs and 18 Retrospective studies were included in this meta-analysis, which involved 1052 eyes in the ILM flap group and 1050 eyes in the ILM peeling group. The overall MH closure rate came out to be in favor of ILM flap technique (OR=2.74, CI=1.62 TO 4.66; P = 0.0002). In overall analysis of postoperative VA, no significant difference was observed between the two surgical methods. However, it favored ILM flap technique on subgroup analysis based on study type and MH size specifically in the RCTS with macular hole size > 400μm (MD = -0.13, 95% CI = -0.16 to -0.09; P < 0.00001) as well as on subgrouping based on follow-up months duration I.e. on all the 3, 6 and 12 months (MD=-0.11, 95% CI = -0.19 to -0.04; P = 0.003), (MD=-0.11, 95% CI = -0.18 to -0.04; P = 0.002) and (MD=-0.12, 95% CI = -0.16 to -0.08; P <0.00001) respectively. Conclusion ILM flap technique resulted in better anatomical outcomes as well as better visual outcomes specifically in larger macular holes and at all the follow-up months. Hence, it is recommended that the inverted internal limiting membrane (ILM) flap method should routinely be chosen as the preferred treatment for patients who have macular holes larger than 400 micrometers.