Macular Buckle, Vitrectomy or combined approach for the management of Macular Hole Retinal Detachment: A Systematic Review and Network Meta-Analysis.

Topic: There is no consensus regarding management of macular hole retinal detachment (MHRD). Techniques such as trans pars plana vitrectomy (TPPV), macular buckle (MB), and combined approach have been described.

Clinical Relevance: To review anatomical and functional outcomes of different surgical interventions for MHRD.

Methods: A systematic literature review was performed following PRISMA guidelines (PROSPERO registration number CRD42024586953). Literature search was performed in PubMed, Embase, Cochrane Library databases and clinical trial databases for randomized controlled trials or retrospective comparative studies reporting MHRD outcomes until 15 February 2025. Retinal reattachment rates, macular hole closure rates, functional outcomes, and complications were assessed. Frequentist Meta-Analysis of Proportions and Bayesian Network Meta-Analysis (NMA) were conducted. Study quality was assessed with Cochrane's ROBINS-I V2 tool and RoB 2 tool.

Results: 5 studies and 308 eyes were analysed. Retinal reattachment rates were significantly higher in combined (96.9%) and MB (96.2%) versus vitrectomy (66.9%). There was no significant difference between combined and MB (p = 0.802; RR = 1.03; 95% CI, 0.94 to 1.12; Tau = 0.00, I = 0.00; GRADE - moderate certainty, 4 studies, 173 eyes), while TPPV did significantly worse relative to MB (p < 0.001; RR = 0.64; 95% CI, 0.50 to 0.79; Tau = 0.00, I = 0.00; GRADE - moderate certainty, 4 studies, 233 eyes). Macular hole closure rates were highest in the combined group (86.0%; MB, 58.4%; TPPV, 46.3%); (Combined vs MB: p = 0.148, RR 1.24, 95% CI: 0.88 to 1.61; Tau = 0.00, I = 0.00%; GRADE, moderate certainty of evidence, 4 studies, 173 eyes); (Vitrectomy vs MB: p = 0.158; RR = 0.73 , 95% CI: 0.40 to 1.05; Tau = 0.00, I = 0.00%; GRADE, low certainty of evidence, 4 studies, 233 eyes). Post-operative visual acuity improvement of MB, combined, and TPPV were logMAR 0.533, 0.510 and 0.434 respectively.

Conclusion: Our study found that compared with TPPV alone, procedures involving MB was associated with better retinal reattachment rates in managing MHRD with moderate certainty. Further studies are required to evaluate macular hole closure rates, visual outcomes and retinal reattachment rates after a combined procedure.