Optimal approaches for managing recurrent macular holes: a comprehensive systematic review and meta-analysis.

BACKGROUND AND

objectiveMacular holes, defined by a central retinal opening, impact vision and are more prevalent as individuals age. Larger holes heighten the risk of persistent issues, leading to recurrent macular holes and presenting treatment challenges. Since 1991, various techniques have been introduced, and new strategies continue to emerge, aiming to enhance closure rates and improve vision correction. Our study seeks to evaluate and compare diverse treatment approaches for recurrent macular holes, emphasizing closure rates and alterations in Best-Corrected Visual Acuity (BCVA).

methodsOur search encompassed four distinct databases-PubMed, Cochrane Library, Scopus, and Web of Science-up to June 2025. We incorporated a diverse range of studies, including cohorts, case series, and randomized controlled trials, that offered relevant data on our subject. Data were extracted from the included studies independently. Our dichotomous outcomes were analyzed using a pooled rate ratio and 95% confidence intervals (CI). Also, our continuous outcomes were pooled in our single-arm meta-analysis as mean change (MC) and with a 95% CI.

resultsOur systematic review and meta-analysis included 72 studies encompassing 2104 eyes included in the analysis. In terms of BCVA among recurrent macular hole treatments, Human amniotic membrane intervention, discussed in 11 studies, showed the highest improvement, with MC of -0.57 and a 95% CI of [-0.71 to -0.43]. Following was retinal expansion, mentioned in five studies, with an MC of -0.54 and a 95% CI of [-0.89 to -0.19]. Autologous lens capsular flap transplantation, discussed in four studies, demonstrated an MC of -0.50 with a 95% CI of [-0.69 to -0.31]. Perfluorethane gas + pars plana vitrectomy (PPV), discussed in two studies only, showed the lowest MC of -0.13 with a 95% CI of [-0.27 to -0.02]. Regarding the closure rate, the Human amniotic membrane showed the highest pooled rate (95.5%), followed by Autologous free internal limiting membrane (ILM) flap (94%), Autologous inverted ILM flap transplantation (90.4%), and the lowest closure rate was found in Perfluorothane gas + PPV (58.6%).

conclusionHuman amniotic membrane emerged as the most effective technique for both closure rates and vision improvement in recurrent macular holes, with a closure rate of 95.5% and a significant improvement in BCVA. Autologous free ILM flaps (93.8%) and autologous inverted ILM flap transplantations (90.4%) also showed high closure rates. In contrast, Perfluroethane gas + PPV had the lowest results in both closure rate and BCVA. Managing recurrent macular holes is challenging due to factors like prior surgeries, residual membranes, and changes in surrounding tissues, necessitating a tailored approach. Despite being the first meta-analysis on this topic with a large population, we lack comprehensive complication evaluation. To overcome these constraints, we propose conducting extensive multicenter randomized controlled trials (RCTs) that directly compare various techniques. These trials should employ uniform evaluation criteria and extend the follow-up duration to ensure robust findings.