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Est-ce que les techniques alternatives de pelage de membrane offrent de meilleurs résultats dans la chirurgie du trou lamellaire? Une méta-analyse et revue systématique de la littérature

Lamellar macular hole (LMH) surgery consists of pars plana vitrectomy with or without membrane (epiretinal membrane/epiretinal proliferation/internal limiting membrane) peeling. Alternative membrane peeling techniques have emerged in recent years to improve outcomes and minimize risk of postoperative complications related to standard membrane peeling in LMH surgery. The purpose of this study is to review the literature on the different peeling techniques used in LMH surgery and compare the outcomes of standard and alternative membrane peeling techniques in LMH surgery using traditional pairwise and proportional meta-analyses.   

A systematic review and meta-analysis was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) Network Meta-Analysis guidelines. Several databases including Ovid Medline, EMBASE, and the Cochrane Library were queried. Pairwise meta-analyses of primary outcomes including mean change in best corrected visual acuity (BCVA) (logMAR) and LMH closure rate between the alternative fovea-sparing peeling technique and the standard peeling technique were conducted. Proportional meta-analyses were used to assess the prevalence of postoperative full-thickness macular hole (FTMH) for each type of peeling.

A total of 61 studies of 1762 eyes reporting surgical outcomes of lamellar macular hole cases were included for the systematic review. Four different peeling techniques were identified throughout the studies: standard integral membrane peeling (n=51 studies), platelet-rich plasma (PRP) foveal injection combined with membrane peeling (n=3 studies), fovea-sparing membrane peeling (n=4 studies), and inverted membrane flap embedding peeling technique (n=7 studies). Fovea-sparing technique was superior to standard technique for improving BCVA (MD -0.21; -0.33 to -0.10) and for LMH closure (RR 1.54; 95% CI 1.10–2.15). In 35 studies of 1458 eyes, a higher proportion of the patients operated with alternative techniques presented with “true” LMH compared to those opeated with standard techniques (proportion 0.57; 95% CI [0.28; 0.82] vs. 1.00 [0.96; 1.00]). The prevalence of postoperative FTMH was higher in the standard peeling group (proportion 0.027; 95% CI [0.014; 0.052]) whereas no postoperative FTMH cases were observed for any of the alternative surgical techniques.

These findings suggest that alternative membrane peeling techniques may offer superior outcomes in terms of BCVA improvement, LMH closure, and a lower incidence of postoperative complications such as FTMH. This study underscores the importance of considering different surgical approaches tailored to the characteristics of lamellar macular hole cases. Limitations of the study include the few number of studies for comparative analyses.

Alternative surgical approaches appear to yield more favorable outcomes for management of LMH compared to the conventional integral membrane peeling. Further comparative studies are warranted to provide deeper insights into the efficacy and safety of alternative peeling techniques.