Operate on the lamellar hole with epiretinal proliferation if it is symptomatic

Design

systematic review with random-effects meta-analysis, surgical and observational cohorts pooled separately

Population

610 eyes across 17 studies with lamellar macular hole and epiretinal proliferation (328 vitrectomy, 282 observed)

Primary outcome

change in best-corrected visual acuity in logMAR, with progression to full-thickness macular hole

Effect

vitrectomy −0.170 logMAR (95% CI −0.254 to −0.086, I²=0%); observation −0.029 (95% CI −0.118 to 0.176); progression 7.5% versus 4.2%, intervals overlapping

Lamellar macular hole with epiretinal proliferation has been managed conservatively largely for want of evidence, and because the appearance on optical coherence tomography looks stable. Seventeen studies covering 610 eyes were pooled, with vitrectomy and observation cohorts analysed separately because direct comparative data were too sparse for a head-to-head synthesis.

In 328 surgically treated eyes across 14 studies, vitrectomy was associated with a pooled acuity gain of 0.170 logMAR (95% CI −0.254 to −0.086; P<0.001) — around eight letters — with heterogeneity of 0%. In 282 observed eyes across 5 studies, acuity did not change (−0.029 logMAR, 95% CI −0.118 to 0.176; P=0.695). Progression to full-thickness macular hole was 7.5% (95% CI 4.0 to 13.6) after vitrectomy and 4.2% (1.4 to 11.8) with observation, with overlapping intervals; bias-adjusted estimates were 12.4% and 10.1% respectively, again overlapping.

The practical shift is in what to tell a symptomatic patient. The old counselling — that surgery risks converting a lamellar hole into a full-thickness one for uncertain visual gain — is not supported here: the progression rates overlap, and the acuity gain in operated eyes is consistent across studies with no heterogeneity at all, which is unusual and reassuring in a surgical meta-analysis.

The design limits how far to take it. These are two separately pooled observational cohorts, not a randomised comparison, and the eyes that came to surgery were selected — more symptomatic, probably worse acuity, with more room to improve. The conclusion that survives is that surgery can be offered to a symptomatic patient with appropriate optical coherence tomography features, rather than deferred by default.

• Offer vitrectomy to the symptomatic patient rather than defaulting to observation
• Base selection on symptoms and optical coherence tomography features, not on the label alone
• Quote a full-thickness progression risk of roughly 8 to 12% after surgery, against 4 to 10% with observation
• Set the expectation at about eight letters of average gain, not restoration of normal vision
• Document baseline acuity and foveal architecture, since the operated cohorts here were self-selected for room to improve

The statistics, in plain English

Heterogeneity of 0% across 14 surgical studies means they all found much the same acuity gain, which is rare and makes the pooled 0.170 logMAR estimate unusually trustworthy as a description of operated eyes. But the two cohorts were pooled separately, so this is not a comparison between randomised groups — the difference between 0.170 and 0.029 logMAR includes whatever distinguished the patients who had surgery. The progression rates have wide, overlapping intervals in both directions, which supports 'no clear increase' rather than 'no increase'.

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