From the Department of Ophthalmology, Stoke Mandeville Hospital, Buckinghamshire NHS Healthcare Trust (Y.A.H.L.), Aylesbury, UK; Department of Ophthalmology, Faculty of Medicine, Cairo University (Y.A.H.L., A.G.E.), Cairo, Egypt.
Department of Ophthalmology, Faculty of Medicine, Cairo University (Y.A.H.L., A.G.E.), Cairo, Egypt; Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami (A.G.E., B.K.W.), Coral Gables, Florida, USA.
Am J Ophthalmol. 2024 Sep;265:165-175. doi: 10.1016/j.ajo.2024.05.001. Epub 2024 May 6.
The optimal management of pediatric traumatic macular holes (TMH) is unclear from lack of prospective randomized trials. The literature is divided into early (≤1month post-trauma), delayed (>1 month) pars plana vitrectomy (PPV), and observation. Our aim is to find which group can achieve best-superior spectacle corrected visual acuity (VA), visual gain, and time for hole closure.
Systematic review.
This systematic review was registered with PROSPERO (ID:CRD42022383134). The databases searched from inception until July 31, 2023, were MEDLINE OVID, Scopus, Web of Science, Embase, and Google Scholar. The articles were screened for title and abstract then for full text. Risk of bias was also assessed. Three outcome measures were analyzed: final VA, visual gain, and time to closure of macular hole (MH). MH size was divided into small (≤250 µm), medium (>250-500 µm), and large (>500 µm).
Ninety eight (98) studies with 234 patients in the PPV group and 87 patients in the observation group were included in the review. Final VA (logarithm of the minimum angle of resolution) and visual gain were respectively in PPV vs observation groups: (1) small MH 0.37 ± 0.52 vs 0.42 ± 0.56 (P = .484) and -0.96 ± 0.83 vs -0.49 ± 0.40 (P = .005); (2) medium MH 0.58 ± 0.39 vs 0.34 ± 0.34 (P = .06) and -0.36 ± 0.42 vs -0.74 ± 0.44 (P < .001); (3) large MH 0.62 ± 0.42 vs 0.59 ± 0.35 (P = .337) and -0.31 ± 0.48 vs -0.62 ± 0.37 (P = .11). Small TMH had comparable closure time: 3.21 ± 2.52 months vs 3.49 ± 4.43 (P = .954) in the PPV and observation groups. Early and late PPV yielded comparable final VA 0.67 ± 0.66 vs 0.54 ± 0.35 (P = .576) and visual gain -0.58 ± 0.69 vs -0.49 ± 0.48 (P = .242) in the PPV and observation groups.
PPV was very effective in closing TMH and VA gain in children throughout a wide range of hole size. Early and delayed PPV yielded similar anatomic and visual results. Observation and PPV yielded comparable final VA and closure time. Clinicians can choose either early PPV or delayed PPV when healing biomarkers are absent on periodic optical coherence tomography.
由于缺乏前瞻性随机试验，小儿外伤性黄斑裂孔（TMH）的最佳治疗方法仍不明确。文献分为早期（≤1 个月外伤后）、晚期（>1 个月）经睫状体平坦部玻璃体切除术（PPV）和观察。我们的目的是确定哪种治疗方法可以获得最佳的矫正视力（VA）、视力提高和黄斑裂孔闭合时间。
系统评价。
本系统评价在 PROSPERO（ID：CRD42022383134）上注册。从成立到 2023 年 7 月 31 日，我们在 MEDLINE OVID、Scopus、Web of Science、Embase 和 Google Scholar 等数据库中进行了检索。文章经过标题和摘要筛选，然后进行全文筛选。还评估了偏倚风险。分析了三个结局指标：最终 VA、视力提高和黄斑裂孔（MH）闭合时间。MH 大小分为小（≤250µm）、中（>250-500µm）和大（>500µm）。
共纳入 98 项研究，PPV 组 234 例，观察组 87 例。最终 VA（最小角分辨率对数）和视力提高在 PPV 组与观察组之间分别为：（1）小 MH 0.37 ± 0.52 对 0.42 ± 0.56（P =.484）和-0.96 ± 0.83 对-0.49 ± 0.40（P =.005）；（2）中 MH 0.58 ± 0.39 对 0.34 ± 0.34（P =.06）和-0.36 ± 0.42 对-0.74 ± 0.44（P <.001）；（3）大 MH 0.62 ± 0.42 对 0.59 ± 0.35（P =.337）和-0.31 ± 0.48 对-0.62 ± 0.37（P =.11）。小 TMH 的闭合时间相似：PPV 组为 3.21 ± 2.52 个月，观察组为 3.49 ± 4.43 个月（P =.954）。早期和晚期 PPV 分别获得了相似的最终 VA（PPV 组为 0.67 ± 0.66，观察组为 0.54 ± 0.35）和视力提高（PPV 组为-0.58 ± 0.69，观察组为-0.49 ± 0.48）（P =.576，P =.242）。
PPV 在治疗儿童 TMH 方面非常有效，可广泛应用于不同大小的 MH。早期和晚期 PPV 均可获得相似的解剖和视觉结果。观察组和 PPV 组的最终 VA 和闭合时间相当。当周期性光学相干断层扫描缺乏愈合生物标志物时，临床医生可以选择早期 PPV 或晚期 PPV。
