Intraocular Tamponade Choice with Vitrectomy and Internal Limiting Membrane Peeling for Idiopathic Macular Hole: A Systematic Review and Meta-analysis.

Topic: A variety of different tamponade agents are used with vitrectomy combined with internal limiting membrane (ILM) peeling for the treatment of idiopathic macular holes. These agents include air, gas (sulfur hexafluoride [SF], hexafluoroethane [CF], and perfluoropropane [CF]), and silicone oil. The optimal tamponade agent is uncertain, and we aimed to review the effect of tamponade choice on hole closure and visual outcomes.

Clinical Relevance: Although most surgeons initially chose to use long-acting gas (CF), there has been a gradual change in practice to the increasing use of the medium- (CF) and short-acting gases (SF) or even air. However, there is no consensus regarding their relative efficacies.

Methods: Systematic review and meta-analysis of randomized controlled trials (RCTs) and prospective and retrospective comparative cohort studies comparing different tamponade agents in patients undergoing vitrectomy and ILM peeling for primary idiopathic macular holes. For RCTs, the risk of bias was assessed using the Cochrane Risk of Bias tool for RCTs, whereas for nonrandomized studies, the Risk of Bias in Nonrandomized Studies of Interventions tool was used.

Results: Thirteen publications, including 2 RCTs, were identified. Overall, there was no significant difference in the anatomic closure rates between studies using SF compared with either CF or CF (odds ratio [OR] = 0.74; 95% confidence interval [CI] = 0.51-1.08). A subgroup analysis showed a significantly higher closure rate using SF (OR = 0.49; 95% CI = 0.30-0.79) in patients without postoperative posturing but not in those who were advised to posture facedown. The visual outcomes and adverse events were not significantly different. The comparisons of anatomic closure rates of patients treated with gas tamponade vs. silicone oil and with air vs. SF showed no significant differences. The included studies had a number of methodological limitations and heterogeneities, making conclusions imprecise, with low or very low certainty by the Grades of Recommendation, Assessment, Development and Evaluation approach.

Conclusion: The current evidence base for tamponade selection with vitrectomy and ILM peeling for full-thickness macular hole has several major limitations. Further appropriately designed studies are needed to guide tamponade selection.