Modified ILM flap techniques versus classical inverted ILM flap technique for large macular holes: a systematic review and meta-analysis of randomized controlled trials

Abstract

Abstract Background Macular holes (MHs) constitute a vitreoretinal interface disorder that occurs when structural abnormalities in the fovea lead to impaired central vision. The standard treatment for MHs is mainly surgical. Using an inverted internal limiting membrane (ILM) flap has enhanced the success rates of MH surgeries. This systematic review and meta-analysis aimed to compare the classical inverted ILM flap technique to modified ILM flap techniques for managing large MHs. Methods We searched Medline, Embase, and CENTRAL. We included randomized controlled trials (RCTs) that compared the classic inverted ILM flap technique to modified ILM flap techniques as initial surgical treatment of eyes with large MHs of more than 400 microns. We sought to evaluate the following outcomes: (1) MH closure. (2) Best-corrected visual acuity (BCVA). (3) Foveal closure type (4) Rate of ellipsoid zone (EZ) defects and external limiting membrane (ELM) defects. The standardized mean difference (SMD) was used to represent continuous outcomes, while the risk ratio (RR) was used to represent dichotomous outcomes. Results Four RCTs that enrolled 220 participants were deemed eligible. The analysis revealed no statistically significant differences in MH closure between both groups (95% CI: 0.20, 7.96; P = 0.81). No statistically significant differences in mean BCVA were found at 1 and 3 months between both groups (SMD: 0.04; 95% CI: −0.16, 0.23; P = 0.70 and SMD: −0.167; 95%CI: −1.240, 0.906; P = 0.760, respectively). In addition, there were no significant differences between the two groups in the pattern of foveal closure, namely U-shape, V-shape, and flap open at 3, 6, and 12 months (RR: 0.87; 95% CI: 0.67, 1.12; P = 0.28, RR: 0.96; 95% CI: 0.58, 1.61; P = 0.89, and RR: 1.95, 95% CI: 0.26, 14.50; P = 0.51, respectively). Finally, the analysis showed no statistically significant difference in both groups’ EZ and ELM defect rates at 3, 6, and 12 months (RR: 1; 95% CI: 0.85; 1.18: P = 1 and RR: 1.14; 95% CI: 0.90, 1.45; P = 0.27). Conclusion Macular holes (MHs) constitute a vitreoretinal interface disorder that occurs when structural abnormalities in the fovea lead to impaired central vision. The standard treatment for MHs is mainly surgical. Using an inverted internal limiting membrane (ILM) flap has enhanced the success rates of MH surgeries. This systematic review and meta-analysis aimed to compare the classical inverted ILM flap technique to modified ILM flap techniques for managing large MHs.